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A COMPENDIUM 

OF 

LECTURES 

ON THE 

THEORY AND PRACTICE 
OE MEDICINE, 



DELIVERED BY 



PROFESSOR CHAPMAN, 



UNIVERSITY OF PENNSYLVANIA. 

PREPARED WITH PERMISSION, FROM DR. CHAPMAN'S MANUSCRIPTS, 
AND PUBLISHED WITH HIS APPROBATION. 

BY N. D. BENEDICT, M.D., 

FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; PHYSICIAN TO THE 
LYING-IN DEPARTMENT OF THE PHILADELPHIA HOSPITAL. 




<yt~ 



PHILADELPHIA: 

LEA AND BLAN CHARD. 

1846. 






u^ 



«►' 



Entered, according to Act of Congress, in the year 1846, 

By Lea and Blanchard, 

In the Clerk's Office of the District Court for the Eastern District of 

Pennsylvania. 









C. SHERMAN, PRINTER, 
19 St. James Street. 



TO DR. CHAPMAN. 

Dear Sir., — 

As a testimonial of my gratitude for many acts of kindness, 
and in view of the assistance you have so generously rendered 
me in the execution of this work, I feel pleasure as well as 
pride, in inscribing the book with your distinguished name. 

N. D. BENEDICT. 



PREFACE 



In presenting this work to the public, the author expects it to 
stand chiefly upon the merits of the great man, in whose volu- 
minous writings it is founded. Elevated on account of extra- 
ordinary talent and learning, at the youthful age of twenty-six, 
to the adjunct professorship of Obstetrics, in the University of 
Pennsylvania, he was, seven years afterwards, elected to the 
professorship of Materia Medica, and, in the thirty-sixth year 
of his age, was transferred to the Chair most congenial to his 
tastes and acquisitions — that of the Institutes and Practice of 
Physic, and Clinical Medicine. 

For many years past, with few living competitors, he has 
stood, confessedly, at the summit of his profession. Distinguish- 
ed for his acquaintance with the opinions of others, he is per- 
haps unsurpassed for originality. 

In all his investigations and speculations, he has shown an 
eminent regard to the practical. Cautious in the reception of 
new observations, or doctrines, he has been remarkably suc- 
cessful in extracting their truths from their errors. The sound- 
ness of every theory and precept, he has tested by a most ex- 
tensive application ; and if the value of a medical writer's 
instructions may be measured by his success in practice, then, 
for the Lectures of Dr. Chapman, from his almost unrivalled 
reputation as a practitioner, is claimed the highest merit. 



v i PREFACE. 

These Lectures, annually delivered to classes averaging four 
hundred members, must be familiar to a large part of the pro- 
fession in the United States ; and we only repeat the " general 
opinion, in pronouncing them, erudite, elaborate, and highly 
finished compositions, enriched with the stores of the most 
varied reading and of ample personal experience." To point 
out another course of medical lectures, at once so profound, so 
practical, and so much to be confided in, would perhaps be 
impossible. The Lectures on Eruptive Fevers, Haemorrhages, 
Dropsies, Gout, and a part of the diseases of the Thoracic and 
Abdominal Viscera, &c, &c. — having been published complete 
in two volumes, are necessarily omitted in this compendium. 

In making this Analysis, distinctness of division, perspicuity 
in expression, emphasis of General Principles and other im- 
portant parts, as well as the closest accuracy, have been care- 
fully studied. 



CONTENTS. 



PAGE. 

REMARKS O.N THE CLASSIFICATION OF DISEASES 17 



FEVER IN GENERAL 19 

INTERMITTENT FEVER 30 

REMITTENT FEVER 42 

CONTINUED FEVER (MILD, INTERMEDIATE, AND EXTREME FORMS) 49 

YELLOW FEVER 71 

EPIDEMIC PNEUMONIC, OR SPOTTED, FEVER 84 

DISEASES OF THE HEART AND BLOOD-VESSELS (INFLAMMATORY, 

ORGANIC, AND NERVOUS) 87 

ACUTE CARDITIS, PERICARDITIS, AND ENDOCARDITIS 91 

CHRONIC CARDITIS, PERICARDITIS, AND ENDOCARDITIS 96 

HYPERTROPHY OF THE HEART 99 

DILATATION OF THE HEART 103 

ATROPHY OF THE HEART 106 

RUPTURE OF THE HEART 107 

AFFECTIONS OF THE VALVES OF THE HEART.... 108 

PALPITATIONS 110 

ACUTE ARTERITIS 112 

DEGENERATIONS OF ARTERIES 114 

ANEURISM OF ARTERIES 116 

PHLEBITIS , 119 

ACUTE INFLAMMATION OF THE THROAT 122 

CHRONIC INFLAMMATION OF THE THROAT 125 

DYSPHAGIA 126 

PAROTITIS 127 



v iji CONTENTS. 

PAGE. 

DYSENTERY (INFLAMMATORY) 129 

DYSENTERY (CONGESTIVE) 136 

DIARRHCEA 139 

CHOLERA MORBUS 142 

CHOLERA INFANTUM 147 

FLATULENT COLIC 153 

BILIOUS COLIC ; „ 157 

COLICA PICTONUM 160 

ACUTE PERITONITIS 164 

CHRONIC PERITONITIS 168 

ACUTE CATARRH 170 

CATARRHUS ^ESTIVUS 175 

CHRONIC CATARRH 176 

ACUTE BRONCHITIS 179 

CHRONIC BRONCHITIS 182 

CATARRHUS SENILIS 184 

ACUTE INFANTILE BRONCHITIS 185 

CHRONIC INFANTILE BRONCHITIS 187 

CROUP, 188 

ACUTE INFANTILE ASTHMA 194 

WHOOPING COUGH 197 

ACUTE LARYNGITIS 201 

CHRONIC LARYNGITIS 205 

PLEUROPNEUMONIA 209 

CONGESTIVE PNEUMONIA 217 

CHRONIC PLEURISY AND PNEUMONIA 220 

APOPLEXY 223 

PALSY 232 

EPILEPSY 235 

HYSTERIA 242 

CHOREA 245 

NEURALGIA 248 

DIABETES 255 



COMPENDIUM 



OF 



DR. CHAPMAN'S LECTURES. 



CLASSIFICATION OF DISEASES. 

Diseases were first classified by Celsus, who associated those 
bearing to each other a general resemblance. A second classi- 
fication was by Ccelius Aurelianus, by whom they were divided 
into the acute and chronic. A third was founded on the locality 
of the disease, beginning with the head, and proceeding to the 
chest, &c. A fourth, adopted by Boerhaave, was founded on 
the supposed causes of diseases. 

The plan of a Nosology, or arranging diseases into classes, 
orders, genera, &c, according to their symptoms, was sug- 
gested by Sydenham, and speedily acted on by Sauvages. 
Since have been elaborated the nosologies of Linnaeus, Vogel, 
Sagur, Cullen, McBride, Darwin, Pinel, Young, and Good. 
These are all marked by great defects ; though the best is that 
of Cullen, improved by the late Professor Hosack of New York. 

Nosology was first attacked by Brown, who supposed all 
morbid states were either sthenic, or asthenic, when compared 
with the standard of health, which he arbitrarily fixed at forty 
degrees. Those, however, loudest in their condemnation of 
nosology, adopt its distinctions. An example is seen in Dr. 
Rush, who held the doctrine of the unity of diseases; and then. 

2 



18 CLASSIFICATION OF DISEASES. 

in the division of his subject calls that by a phrase, which had, 
before, been designated by a word. 

Notwithstanding the features of a disease are modified much 
by circumstances, yet there are leading characteristics which 
still remain to isolate it. In order, however, to attain to a proper 
arrangement, our views require great improvement, since the 
arrangement ought to be based upon pathological conditions. 
Nosology has greatly declined. 

Dr. Chapman assorts diseases, as they are presented in the 
different systems of the body. Yet, he confesses that this too 
has its defects, among which is, chiefly, that each system is 
composed of heterogeneous elements, each of w T hich may be 
separately affected, and require a peculiar treatment. Yet, on 
the whole, he considers his plan the best ; and it has been fol- 
lowed by many distinguished writers. 

Limiting the term system to a part, or combination of parts, 
having a similarity of structure, or which concur in the same 
uses, the following may be stated : 

!. The Circulatory, consisting of the heart and blood-vessels. 

2. The Alimentary, of the stomach and bowels. 

3. The Secretory, of the glandular apparatus. 

4. The Absorbent, of the lacteals and lymphatics. 

5. The Respiratory, of the pulmonary organs and their im- 
mediate extensions. 

6. The Perspiratory, of the external covering of the body. 

7. The Sensitive, of the brain, spinal marrow, nerves, and 
organs of sense. 

8. The Muscular, of the muscles, and their appendages. 

9. The Osseous, of the bones and their connexions. 

10. The Generative and Urinary, of the organs subser- 
vient to these processes in both sexes. 

A part of what is embraced in this Physiological Division, 
will be resigned to the departments of surgery and midwifery. 
As much regard as possible will be paid to the distinctions 
arising from the peculiar tissue in which the disease may be 
located. The best classification would be that founded upon 
the tissues of the body, but it is impracticable from the usual 
engagement of several tissues in the same affection. 



FEVERS. 



It has been estimated that one-half, and by Sydenham that 
one-third of mankind die from fever. 

What is Fever 1 Cullen, who on this point has been chiefly 
followed, defines it to consist in preternatural heat, and frequency 
of pulse, after a shivering, accompanied with a disturbance in 
many of the functions, and diminution of strength, especially in 
the limbs. Of the constituents of this definition the first three, 
viz., preternatural heat, and frequency of pulse, and antecedent 
shivering, are not uniform attributes of fever. The last two, 
disturbance of the functions, and debility, belong equally to other 
affections. So exceedingly diversified are the manifestations of 
fever, that though it may be easily recognised, yet an adequate 
idea of it can only be conveyed by a description, such as shall 
embrace the entire assemblage of appearances from its com- 
mencement to its final termination, and in all the varieties of 
which it is susceptible. This will be the proper substitute for a 
definition, and will be executed in the special consideration of 
fevers. At present will be given a mere summary. 

SYMPTOMS OF INFLAMMATORY FEVERS. 

PREMONITOR Y. — Nearly always, languor, listlessness, disin- 
clination to motion, and some feebleness. Concomitantly, or soon 
after, anorexia, nausea, eructations, or other disturbance of the 
stomach, — irregularity of bowels, which are usually costive, 
with uneasiness in them, furred tongue, — pains in the back and 
extremities, with slight tremulousness, — skin harsh and unper- 
spirable, pale and shrivelled, — countenance sunken, or otherwise 
changed, — headache, or giddiness, — the mind perhaps dull and 
confused, and the temper petulant and fretful. 



20 DISEASES OF THE CIRCULATORY SYSTEM. 

OF THE CHILLY ST A GE.— The case is gradually evolved 
by an increase of the foregoing symptoms, and especially by the 
sense of chilliness. Cold is felt in the back, as if a stream of water 
were trickling down it, quickly followed by shiverings, or even 
convulsive rigors. Respiration short and hurried, — vomiting, — 
mouth dry and clammy, — thirst considerable, — circulation quick 
and feeble, — and the muscular pains exasperated. This stage 
continuing an indefinite period, is succeeded by the 

STAGE OF REACTION.— Pulse vigorous, tense, and acce- 
lerated, — extreme vessels full, — temperature restored, — respira- 
tion somewhat freer, — countenance florid and tumid, — severe 
headache, — and great depravation of the secretions. 

Thence, the progress and eventuation are determined by the 
type. 

Such are the leading symptoms of inflammatory fevers, which 
are, however, greatly diversified in degree of violence and com- 
plication. 

SYMPTOMS OF FEVERS OF A TYPHOID KIND. 

In such fevers from the primary action of the cerebral and 
nervous systems, or from improper management, reaction is 
withheld, and hence appears the aspect of extreme prostration, 
and of slow and imperfect developement. 

THE ACCESSION.— This is very sudden. There is felt a sense 
of coldness, or a decided chill. Skin pallid, or mottled, and 
collapsed, often dripping with a dewy perspiration, — pulse small 
and feeble, or full, irregular, and easily compressible, — strug- 
gling of the heart, respiration slow and heaving, — muscular 
power exceedingly impaired, — and intellectual powers dull or 
confused. 

Should the system emerge from this state, then is developed 
the stage of 

PARTIALREACTIO N.— This state marked by hot head and 
cold feet, and great cerebral and nervous distress. 



FEVER IN GENERAL. gj 



IRRITATIVE FEVER. 

In this, the original impression is made on the nervous sys- 
tem, and to it subsequently is the impression chiefly confined. 
The case having begun with feelings of intense wretchedness, 
which may last many days, a fever ensues of a diminutive 
kind, exceedingly lingering, marked by extreme debility, and 
presenting the appearance of nervous irritation. 

The congestive and irritative forms of fever, like the inflam- 
matory, occur in the intermittent, remittent, and continued types. 

CAUSES OF FEVER. 

PREDISPOSING.— Excessive heat or cold; sudden varia- 
tion of temperature ; humidity, or dryness of atmosphere ; 
extreme rarity or density of air; calms or tempests; the steady 
prevalence of certain winds ; and marsh miasmata or impreg- 
nations received by the air from marshes. Emanations from 
animal putrefaction, and mineral fumes are excluded by Dr. 
Chapman, from this category. Crowding people in ill-venti- 
lated apartments, which may act either through contagion 
arising from disordered secretion, or as Dr. Chapman thinks, 
from excess of oxygen, or carbonic acid, or both. At all 
events, to this vitiation belongs properly the term Malaria, and 
not Miasma, which relates only to vegetable emanations. Con- 
tagion, as in eruptive fevers, acting either by contact, or through 
the atmosphere. Corrupted or penurious food. Mental emo- 
tions, sometimes of an exalting though more usually of a de- 
pressing kind. An inexplicable epidemic influence. 

EXCITING. — In a number of individuals exposed equally to 
the predisposing causes, we see a great difference in the suscep- 
tibility to impression. The agencies promotive of this suscep- 
tibility are called exciting causes. These are : 1. A peculiar 
organization. 2. The irritation of one or more organs, which 
according to the ancient maxim, ubi irritatio, ibi affluzus, solicits 
and directs the aggression of disease. This action is well shown 



22 DISEASES OF THE CIRCULATORY SYSTEM. 

in revulsives, when used to invite disease from one part to an- 
other. But the doctrine here advanced is very contrary to that 
which was promulged by Brown, supported by Rush, and which, 
although it has lost caste with the profession, is still employed 
in the common parlance of both physicians and the vulgar. The 
other theory ascribes the increased susceptibility to debility. 
It maintains that disease will fall upon a weak organ. But it is 
contradicted by the fact, that it is the robust who are usu- 
ally the subjects of the attack ; that in seasons of widespread 
danger, the protective measures employed are of a lowering 
character, as they are also when used as precautionary to the 
fever which it is apprehended will follow a- wound. 

Under this second head, then, all irritating and perturbating 
agencies are included. — Indiscretions in diet, or clothing; ex- 
posures to heat or cold, violent exercise, mental emotions, con- 
stipation, acrid secretions retained in the body, &c. 

D I A G N S I S. — It will be here only stated that the diagnosis 
is easily made. The farther consideration is pretermitted until 
the fevers are taken up in detail. 



PROGNOSIS. 

The discussion of this will also be brief in this place. The 
more a febrile attack is diffused over the system, the less dan- 
gerous it is. The most tractable of fevers, are intermittents ; 
the least so, are the continued, and especially those of a con- 
gestive or typhoid character. By some indeed it is maintained 
that the latter class cannot be cured by art, but only mitigated. 
Proof is drawn from the eruptive fevers. But it is unfair to 
draw such a general inference from fevers so peculiar in na- 
ture. This theory is directly disproved by facts. Still there is 
a disposition in fevers to a spontaneous crisis on certain days, 
and the difficulty of arresting them on intermediate days is 
great. 

CRITICAL D A Y S, or those in which a fever always has a 
tendency either to abate or become exacerbated, were first ob- 



FEVER IN GENERAL. 33 

served by Hippocrates, and since have been fully shown to 
exist. According to Hippocrates, the critical days are the 3d, 
5th, 7th, 9th, 11th, 14th, 17th, and 20th, or as some commenta- 
tors declare, the 21st; and since have been added the 27th, 35th, 
and 42d days. The vigour of our practice is rather unfavour- 
able to the clear manifestation of these crises. 

The occurrence of critical days has been explained on the 
supposition that continued fevers are really disguised intermit- 
tents, which, commencing as quotidian, or tertian, become 
quartan on the 11th day. Crises are denoted by haemorrhages, 
especially from the nostrils, and haemorrhoidal vessels, im- 
proved and augmented secretion, and subsidence of the febrile 
movement; and these changes act, like our artificial evacua- 
tions, rather as causes than effects merely of an ameliorated 
condition. Fevers, however, sometimes subside gradually. 

AUTOPSIC APPEARANCES. 

The phenomena exhibited are mainly seated in the alimen- 
tary canal, and collatitious viscera, brain, and spinal marrow. 
Lesions also probably exist in the nerves, particularly the gan- 
glionic centres, though seldom demonstrable. The upper por- 
tion of the alimentary canal, with the liver, pancreas, and spleen, 
are most apt to be implicated ; and next, the brain and its de- 
pendencies. Phlogosis and congestion, with their varied results, 
constitute the morbid conditions presented. 

PATHOLOGY. 

The question now agitated is, whether fever is the conse- 
quence of some primary local irritation, followed by a series of 
morbid associations, to a greater or less extent, — or, is the 
original impulse of a general nature, giving a* shock to the 
entire frame, and the topical irritation, or inflammation, secon- 
dary and dependent] This is only the revival of the old discus- 
sion ending partly by common consent, in the division of fever 
into symptomatic and idiopathic. Dr. Chapman regards all 
fevers as sympathetic of a primordial local disturbance. The 



24 DISEASES OF THE CIRCULATORY SYSTEM. 

settlement of this subject he deems of much practical impor- 
tance. 

ILLUSTRATION AND PROOF OF THE PROPOSITION. 

— In the phlegmasia?, — in fever following injuries, and the recep- 
tion of poison, — in fever produced by irritants, as worms, — and 
in the eruptive fevers, it is undisputed that the febrile action is 
merely sympathetic of the local disturbance. Tracing out the 
evidence, we may also be persuaded that the same holds true in 
its application to the so-called idiopathic fevers. These fevers 
are caused mainly by contagion, or other effluvia, as marsh 
exhalations, or by excesses of temperature, or sudden transitions 
of weather, or some general, or epidemic agency. 

Now it is plain that such atmospheric impregnations are only 
admitted by being entangled in the saliva and swallowed. The 
truth of this is evinced by the protection afforded against such 
impregnations, and the poisonous fumes of certain metals, by 
taking food or oil into the stomach previously to exposure. 
These act either by sheathing the sentient surface, or by bring- 
ing on digestion, in which process the deleterious properties of 
the morbid agents are destroyed. The early phenomena, also, 
are decidedly gastric. Still, supposing the lungs to be the 
avenue of admission, the general proposition respecting a local 
origin of fever, is not invalidated ; in that case, the lungs, instead 
of the stomach, would be the primary seat of morbid action. 

Cold, also, by inducing torpor of the skin, drives in the blood 
and concentrates the sensibility upon internal parts, from the 
disturbance of which radiates disorder to every part of the 
economy. Heat, having first stimulated the cutaneous surface 
beyond measure, when withdrawn, leaves it in a torpid condi- 
tion, which acts in the production of visceral disease, in the same 
manner as when proceeding from cold. This will suffice for an 
illustration of the modus operandi of the causes in the production 
of fever. 

From the greater exposure and the more widely spread sym- 
pathies of the stomach, we might a priori apprehend its irrita- 
tions to be a common source of fever. And, in fact, they are 
the source of nearly the whole of the idiopathic or essential 



FEVER IN GENERAL. 25 

fevers of writers, and certainly of our autumnal fevers. For 
proof, look at the principal phenomena of their developement, 
which are eminently gastric. The same may be said of the 
origin of the eruptive fevers ; and their early phenomena may 
be pointed to as evidence of their ventricular origin. From 
dissection, too, do we derive impressive proof of the same thing. 

But though the primary impression be seated in the stomach, 
yet this may be superseded altogether by the prepotency of a 
sympathetic impression on some other viscus, as the liver, or, 
in typhoid or congestive fevers, the brain. 

Dr. Chapman believes that no unnatural substance enters the 
blood in a healthy state, unless by injection. Yet he believes 
the blood in fevers does occasionally become much changed, and 
reacts on the solids, in the production of an increased degree of 
the typhoid or congestive tendency. But the deterioration of 
blood is effected through the mediation of a nervous system 
which is antecedently deranged. The blood in the commence- 
ment of fever, if examined, will be found little, or not at all altered. 

It has been inculcated by some that the primary impression 
in fever is seated in the circulatory machinery. But the red 
discoloration of phlogosis, reported as such by Bouillaud, has 
been proved to be merely the infiltration of blood into the texture 
after death. Indeed, the phenomena of inflammation of these 
parts are very different from those of fever. 

We have seen how fever is effected by a sympathy radiated 
from the part or parts on which the morbid impression has been 
made. But what is the essential nature of fever? Of this, or, 
in other words, of the intimate changes in the organization 
which constitute it, we may expect to know nothing. We 
must be content with tracing its well-ascertained phenomena. 

The primary irritation (which is a disturbance of the normal 
functions of the nerves) gives rise to symptoms declaratory of 
sympathetic nervous and cerebral affection. These constitute 
the premonitory symptoms of fever. The internal irritation 
inviting an afflux of blood from the cutaneous surface, occa- 
sions the symptoms already described as those belonging to the 



26 DISEASES OF THE CIRCULATORY SYSTEM. 

stage of the chill. The state of irritation and congestion in the 
viscera is followed by inflammation. In case the system, how- 
ever, be overwhelmed by the force of the remote cause, reac- 
tion may be refused, and the turgid condition, characterized by 
the features formerly described, continues. Should inflamma- 
tion be set up, there result the phenomena of fully developed 
inflammatory fever. 

The conversion of congestion into inflammation appears to be 
effected thus. In order to overcome the impediment to the 
capillary circulation, the heart and great vessels are additionally 
excited. Should the obstruction be removed by the vis a tergo, 
all does well. But the obstruction remaining, inflammation 
results, which, from an extensive play of sympathies, induces 
the commotion of system described by the term, a perfect 
fever. That the febrile movement is primarily caused by the 
topical lesion, is proved by the fact that where such lesion does 
not exist, whatever may be the violence of the circulation, there 
is no fever. It is only the extension of irritation from the local 
lesion to the capillaries throughout the system, which can give 
rise to the various functional derangements, such as vitiated 
secretion, increased or diminished evolution of animal heat, and 
other derangements depending on a disordered condition of the 
capillaries. 

Dr. Chapman does not, like Broussais, confine the primary 
seat of irritation to the upper portion of the alimentary canal, 
but maintains that any susceptible surface may become the seat 
of the first attack, or by metastasis, or otherwise, may assume, 
in the progress of the case, the most prominent position. 

That the stomach suffers in every case of continued fever, is 
contradicted by the observations of Andral, Louis, and others. 
Broussais's idea, that every impression is transmitted to the 
brain, and thence reflected to the stomach, is gratuitous. 

Louis located the origin of fever in the glands of Peyer and 
Brunner; Clutterbuck in the brain; others have located it in 
the spinal marrow, the liver, the skin, blood-vessels, or some 
other part. 

Dr. Chapman regards fever as being the product not only of 



FEVER IN GENERAL. 



27 



inflammation, but also of irritation simply, or of congestion. If 
fever depend wholly on inflammation, it ought to vary in inten- 
sity with the intensity of the inflammation, which is by no means 
the fact, as is shown in the case of corrosive poisons. 

Genuine fever is an affection of the whole economy, though 
rarely affecting two parts in equal proportion. 

The only true test of theory is practical experience. Do the 
theory of fevers as just advanced, and the best practice in their 
management, correspond? They will be shown to do so entirely. 
This will prove confirmatory of the theory; and even should the 
theory be really false, it will entitle it to regard, since the great 
end of a correct theory would still be fully attained, namely, 
clear indications to good practice. 

Being called to a case, which we are convinced depends on 
some gastric irritation, whether arising from miasma, conta- 
gion, accumulation of acrid bile, or some of the other causes we 
have previously detailed, is not the first suggestion of reason to 
remove the irritating agent by an emetic or purgative? And 
is it not well known that an emetic or purgative, given in the 
early stage of miasmatic fevers, typhus, and especially the exan- 
themata, sometimes completely arrests their progress? which it 
must do by removing the offending matter, or by breaking the 
links of the forming chain of association, and in either case 
coinciding with the theory. 

But as in the phlegmasia?, which if early treated can be cured 
by topical means, but which having involved the system in a 
febrile movement, must be treated by general measures, so in 
the fevers called idiopathic; since in an advanced stage the 
morbid action throughout the organization, has become nearly 
independent of its source. 

Lest these views of pathology should be thought to have 
been taken from Broussais, it may be stated that they were 
announced by Dr. Chapman, long anterior to any of Broussais's 
writings. 



28 DISEASES OF THE CIRCULATORY SYSTEM. 



TREATMENT. 

1. Ascertain whether the fever be intermittent, remittent, or 
continued; — whether it be irritative, congestive, or inflamma- 
tory, — simple, or complicated, — and to what stage it has ad- 
vanced. 

2. Inquire the age, previous health, constitutional vigour, 
habits of the patient, and his capacity to bear the operation of 
remedies. The sex is also to be regarded. 

3. Consider the nature of the prevailing epidemic, and calcu- 
late the modifications it will be likely to impart to the fever. 
This modifying influence of epidemics is often of very great im- 
portance. 

The fever being Inflammatory, the chief indication is, com- 
monly, to reduce the excess of reaction. 

For this purpose, we resort to the following remedies. 

Venesection, then cups or leeches to the local affection. 
Emetics, purges, cold applications to the surface, antimonials, 
and other febrifugic articles. Should, however, the febrile 
action, in a mitigated state, persist, as it does sometimes, we 
must resort to blisters, or other revellents, to mercury as an 
alterative, and sometimes to a more powerful mercurial im- 
pression. 

The case being congestive, we must determine whether this con- 
dition be active or passive. In the former instance its manage- 
ment should be nearly the same with that of inflammatory fever. 
But the vital powers being evidently depressed, we must at once 
invigorate them by internal stimuli, frictions, sinapisms, and 
other exciting applications externally. Adequate reaction having 
been attained, these measures may be relinquished for the 
evacuant means already mentioned, though very cautiously, 
lest by the supervention of exhaustion, the system relapse into 
prostration. 

FEVERS OF IRRITATION are to be treated by gentle 
evacuations from the alimentary canal, and small local bleed- 
ings; active measures being avoided. 



FEVER IN GENERAL' 29 

REMITTENTSANDINTERMITTENTSaretobe treated 
during their periods of exacerbation on the principles of more 
continued fever; but during the remissions, and especially the 
intermissions, a class of articles, such as Peruvian bark, are to be 
used for the prevention of the paroxysm. 

The diet and regimen should be accommodated to the state 
of the system. 

Though the so-called idiopathic, or essential fevers as more 
recently entitled, differ not in principle from the phlegmasia?, 
yet in conformity with custom, Dr. Chapman deems it advisa- 
ble to treat of them separately. They have been divided into 
synocha, or purely inflammatory, — synochus, of the same condi- 
tion, though of less degree in the commencement, with a ten- 
dency to degeneration as it advances, — and typhus, when this 
low state of the vital powers prevail from the inception to the 
end. 



FEB HIS INTERMITTENS, OR 
INTERMITTENT FEVER. 



This fever consists of a succession of paroxysms, between 
each of which there is a distinct intermission, or subsidence of 
the febrile state, called apyrexia. The period from the be- 
ginning of one paroxysm to the beginning of another, is called 
the interval; and that from the end of one to the beginning of 
another, the intermission. The paroxysm recurring daily, the 
intermittent is entitled quotidian ; every other day, tertian ; and 
when the attack reverts only once in three days, it is called 
quartan. The attacks are said to recur sometimes much more 
seldom, e. g., once a year. Dr. Chapman is convinced that the 
disease having ceased, has a tendency to reappear on the 8th, 
15th, and 22d days of its cessation, as well as semi-annually, 
or annually. The types are sometimes complicated. There 
may be, for instance, the double tertian, with two paroxysms 
every other day ; or with a paroxysm every day, the alternate 
paroxysms corresponding. These complications are rare. Of 
all the types, the tertian is most frequent, and the quotidian next. 
The quartan most frequently arises from neglect or ill manage- 
ment of the other varieties. Commonly the quotidian occurs in 
the morning, the tertian at noon, and the quartan in the evening. 

Each paroxysm is divided into the cold, hot, and sweating 
stages. 

SYMPTOMS OF THE INFLAMMATORY FORM. 

COLD STAG E, — Languor, chilliness, nausea, pallor ; soon after, 
shiverings, or even violent rigors, with increased pain in the 



INTERMITTENT FEVER. 31 

head, loins, and extremities. Sometimes vomiting, with urgent 
thirst, and frequently copious discharges of pellucid urine. 

The mind also is irritable and childish. When the natural 
powers are feeble, or the force of the attack is overwhelming, 
the blood determined upon the internal organs, remains. 

The cold stage having continued from half an hour to an hour, 
or sometimes longer, reaction succeeds, inducing the 

HOT STAG E, — Hot surface, flushed face, violent headache, 
anxiety, stomach generally disordered, bowels unmoved, urine 
red. Pulse slowly becomes voluminous and vehement. This 
state continuing from three to twelve hours, the 

SWEATING STAGE supervenes with great relief. The func- 
tions are restored to a state comparatively healthy, The urine, 
in the former stage clear and red, is now a little turbid, and 
deposits a whitish sediment ; unless a crisis is about to take 
place, when the sediment is lateritious, or brick-dust-like. 

DURATION. — Twelve hours are given as the ordinary dura- 
tion of a tertian, though it may extend to eighteen. Each of 
the stages has sometimes been absent. Sweating has been 
substituted by discharge from the kidneys. 

All the stages of a tertian are more severe than those of a 
quotidian. The quartan is in severity like the tertian, but is 
distinguished for slightness of perspiration. 

The case has sometimes been restricted to one part of the 
system, — the limbs, for instance. Intermittents are sometimes 
masked by other diseases, which fact it is of importance to 
detect. 

SYMPTOMS OF THE CONGESTIVE FORM. 

Coming on with debility, the chill is either violent for a short 
time, or is very slight, or is alternated with feverish flushes, or 
very speedily heavy congestion supervenes in one or more vis- 
cera. Such an attack is rarely followed spontaneously by a 
normal hot or febrile stage. Continuing from six to eighteen 



32 DISEASES OF THE CIRCULATORY SYSTEM. 

hours, the coldness is succeeded by clammy or dewy perspira- 
tion. The intermission is imperfect, and the succeeding parox- 
ysm appears at an earlier hour. The pulse is nearly extinct, or 
low, hobbling, full and compressible, — the tongue moist and 
milky, — skin cold and damp, with, sometimes, a very unequal 
temperature. The engorgement of the brain and lungs occa- 
sionally amounts to apoplexy. 

Cases occur in which there is little consciousness of danger 
and little apparent suffering, and in which the patient may con- 
tinue to walk about the house, that are prone to terminate sud- 
denly in a swoon. Reaction, however, does sometimes take 
place, in force sufficient to accomplish a recovery. 

In other instances the force of the disease seems to be ex- 
pended on the primse viae. Here there is great gastric disorder, 
jactitation, a moist tongue, with a disposition to syncope. At 
times, without any chill, fever, or prominent symptom, the 
patient is seized with meteorism, copious discharges from the 
bowels, sometimes emesis of a thin turbid fluid, and occasion- 
ally cramps of the muscles. Coming on in the same way, but 
without disturbance of the alimentary canal, there may take 
place an excessive and debilitating cold sweat. 

In all these cases, reaction is rare ; but taking place, if 
moderate, it produces a low congestive fever. If it be forcible, 
the fever is of a higher grade, and there is a peculiar determi- 
nation to the brain. 

A PYRE XI A. — During the apyrexia the pulse is not right, 
and there is disorder of the alimentary canal. Indeed, all 
the secretions and excretions are vitiated. Mind and body 
are both deficient in tone. The apyrexia is marked also by 
sallowness of complexion, uncomfortable feelings in the hy- 
pochondria, or head, with an increased sensibility to cold. 
In the graver varieties the apyrexial disorders are still greater, 
and the tendency of one paroxysm to encroach on another, 
leads to the formation of remittent, or of low continued fever. 



INTERMITTENT F E V E R. 33 



CAUSES. 



REMOTE. — Marsh Miasmata. Dr. Chapman thinks he has 
elsewhere (in his treatise on Epidemics), shown that these mias- 
mata proceed from soils (particularly the argillaceous), and not 
from the decomposition of organic matter. They are commonly 
ascribed to vegetable decomposition. 

EXCITING causes, and not, as has been supposed, predispos- 
ing causes also, are extreme heat of the atmosphere, indiscretions 
in diet, accumulations of bile, &c. Confounding intermittent 
with hectic, some of the late writers attribute it to a variety of 
local irritations. It occurs at times as an epidemic ; and so 
occurring, is apt to be more malignant, or mixed and ambiguous 
in character, requiring, therefore, a close diagnosis. No age is 
exempt. 

DIAGNOSIS. 

The intermission is the most distinctive trait. The time of 
year, exposure of the individual to miasma, and the symp- 
toms of a developed attack will assist in the diagnosis. In pa- 
thology it most resembles remittent, but in external physiognomy, 
hectic fever. Intermittent and hectic thus differ: 

] st. The paroxysms of hectic want that agony in the spine 
and limbs, so characteristic of intermittent. 

2dly. The paroxysms of hectic are seldom uniform for any 
number of days in succession, and after a short time, may come 
on at any hour of the day or night. Two paroxysms occur 
mostly in the twenty-four hours. 

3dly. The paroxysm of hectic is often destitute of the chilly, 
and sometimes of the other stages. 

4thly. The sweating stage of hectic does not always afford 
relief; on the contrary, chills and flushes may come and go at 
the same time. 

5thly. The flush of the cheek in the hot stage of hectic, is cir- 
cumscribed and peculiar. There is no headache ; but the joints 



34 DISEASES OF THE CIRCULATORY SYSTEM. 

of the lower extremities, apt after a time to be swollen, become 
in the hot stage extremely painful. 

6thly. The pulse in hectic does not subside with the parox- 
ysm, and in every respect is the apyrexia less complete. 

7thly. The tongue in hectic is clean, florid and polished ; in 
intermittents, is covered with a whitish or yellowish fur. 

8thly. The alimentary canal is healthy in hectic, but the re- 
verse in intermittent. 

9thly. The urine in hectic is usually turbid during the parox- 
ysm, and clear in the intermission, but reversely in intermittent. 

lOthly. The mind in hectic is cheerful, while it is the opposite 
in intermittent. 

PROGNOSIS. 

Tertian is the most manageable type, the quotidian being apt 
to degenerate into remittent or continued fever. Favourable 
signs, are a complete chill, which foretells an efficient reaction ; 
the retardation of the paroxysm ; cleaning of the tongue ; bilious, 
or dark, tarry and offensive stools; lateritious sediment in 
the urine ; and scabby eruptions about the mouth. The unfa- 
vourable signs, are the premature appearance of the paroxysms, 
and complication with other disease. The case will be more 
intractable also in proportion to its duration, which results as 
well from the force of habit, as from the disorders of the chylo- 
poietic and other viscera. A violent paroxysm, when simple, 
is not the most dangerous, but frequently proves the final 
attack. 

The disease is dangerous to the infirm. Children are easily 
cured. The intermittent may terminate by a conversion into 
remittent or continued fever, or it may run into a chronic state, 
and by long protraction, derange the organs. In this latter way 
.it lays the foundation of other diseases — as certain affections of 
the heart or lungs, or inflammation, or congestion of the abdo- 
minal viscera, with jaundice, and especially dropsy. 

The nervous system may also become deranged, and parti- 
cularly with neuralgia. This last, supposed by some to be a 



INTERMITTENT FEVER. 35 

late disease, was formerly designated by different terms, such 
as rheumatalgia, lumbago, gastralgia, &c. 

Death occurring suddenly during the cold stage of a pa- 
roxysm, it is usually from engorgement of the viscera of the 
^reat cavities; occurring during the hot stage, it is from con- 
vulsions arising from excitement of the brain, or spinal marrow. 
The sweating stage is scarcely ever fatal, except in malignant 
and congestive cases. 

AUTOPSIC APPEARANCES. 

Death happening in acute cases in the cold stage, the chief, 
if not only appearance, is that of engorgement in one or more 
viscera. Death happening in the hot stage of an inflammatory 
attack, or after a series of paroxysms, phlogosis is displayed in 
the brain, its meninges, or those of the spinal marrow, in the 
pulmonary apparatus, or in the abdominal viscera. Congestive 
cases, death occurring at any stage, display immense engorge- 
ments and traces of weak inflammation. In chronic cases are 
revealed all kinds of organic depravation of the abdominal vis- 
cera, with frequent hydropic effusion. 

PATHOLOGY. 

Many attempts have been made to account for the periodical 
nature of intermittents, but they have all, so far, been unsatis- 
factory. It has been alleged, in solution of the difficulty, that 
the paroxysm ceases in consequence of the excitability of the 
system being exhausted, and when this is recruited, the pa- 
roxysm is renewed. But among other objections, it may be 
asked: — Why, then, are not all diseases periodical? 

Another question is, What is the nature of the action ? It is 
commonly asserted to be that of irritation, congestion, or in- 
flammation. That these latter states should come and go so 
rapidly, may seem strange; yet post mortem examination re- 
veals such phenomena, and the sudden accession and departure 
of inflammation in rheumatism and in gout, furnish a confir- 
matory analogy. 



36 DISEASES OF THE CIRCULATORY SYSTEM. 

Again, What is the seat of this action? It is generally alleged 
to be seated in the stomach and intestines. Chronic cases are 
undoubtedly kept up by disease in other viscera. But in view 
of the great similarity to remittent and continued autumnal 
fevers, in causes, symptoms, and treatment, and the converti- 
bility of intermittent into them, Dr. Chapman regards the ac- 
tion as essentially gastro-enteric, and the other viscera as af- 
fected sympathetically. 

In recent and in mild cases, there is probably irritation only, 
with temporary congestion, while in confirmed ones there ex- 
ists inflammation with its organic derangements. 

In congestive and malignant cases, either from a primary 
want of constitutional vigour, or from the overwhelming action 
of the remote cause upon the brain and nervous system, the 
blood recedes from the skin to the deeply-seated organs, pro- 
ducing the heaviest engorgements, and this without the power 
of due reaction. 

TREATMENT OF THE PAROXYSM. 

INFLAMMATORY FORM. 

COLD STAG E. — To overcome the chill, we place the patient 
in bed, cover him well, make hot applications to the lower ex- 
tremities, and administer warm beverages. The mischief, how- 
ever, taking place principally in the cold stage, should it be 
protracted, or the prostration be considerable, we resort to 
more efficient measures. For this purpose have been used, 
ether, carbonate of ammonia, camphor, &c. But the best is 
opium, or its preparations. The application of the tourniquet 
to an upper and lower extremity, is not deserving of much con- 
fidence. More may be expected from friction along the spine, 
or a sinapism to the epigastrium. 

Venesection, useful in many cases of heavy engorgement, 
is unnecessary in ordinary cases. It is a practice introduced 
and recommended by Macintosh, but is adapted only to some 
cases, and is pernicious in others. 

The substitution of cold for hot applications, has sometimes 
succeeded, by reviving, probably, cerebral and nervous energy. 



INTERMITTENT FEVER. 37 

HOT STAGE, — The indication here is, to promote sweating. 

Emetics. — These may be premised when the stomach is 
irritated by bile or other matter. 

Diaphoretics. — Acetate of ammonia, or sweet spirits of 
nitre, with laudanum ; or, better, especially where there is much 
gastric disorder, the effervescing draught, or neutral mixture. 
But with such a view, the following is incomparable.* Opium 
may be used very advantageously in patients who are not 
plethoric. 

Intense fever arising, as it sometimes does, with strong and 
dangerous local determination, it becomes us to use the lancet, 
local bleeding, purging, and other auxiliary measures. When 
the constitution is vigorous, and the fever well established, 
enemata of cold water may be advantageously employed. 

SWEATING S T A G E— Here, nothing more is needed than 
to wipe the patient dry, and give him dry clothes, to check the 
discharge, when excessive. 

CONGESTIVE FORM. 

Here the system may pertinaciously refuse to react, while the 
most important organs suffer from venous congestion. In con- 
sequence of such congestion of the brain, may be induced 
apoplexy, or coma. 

Venesection, which may seem to be indicated, will perhaps 
be inconsistent with the exhaustion of the vital functions. 

Topical Bleeding, must therefore be substituted. 

Emetics, — Especially of salt and mustard, which do not 
leave behind them protracted nausea and gastric debility. 

Sinapisms to the stomach, neck, and extremities. 

Opiates, eminently useful in the chill of common inter- 
mittens, are here both safe and efficacious. Indeed, in most 

* R. — Aeac. Gum. ; 

Potass, carb., aa. 3j. ; 
Ol. menth., gits. vi. ; 
Tinct. opii, gtts. xxx. ; 
Aq. font. f3iv. 
A tablespoonful every half hour, to be followed with a small portion of lemonade. 



38 DISEASES OF THE CIRCULATORY SYSTEM. 

disturbances of the brain connected with miasmatic fevers of any 
type and any stagey opiates are far more serviceable than is 
generally supposed. 

Cases occur, also, where there is dangerous collapse, without 
extreme concentrations of blood. These cases are to be 
managed by external warmth, sinapisms, cordial stimulants, 
carbonate of ammonia, camphor, and opiates. 

Examples, moreover, of the disease are met w T ith, where the 
whole force seems to be expended on the alimentary canal, pro- 
motive of incessant puking and purging. Here, use opiate 
enemata and external irritants. 

The sweating being excessive, the most effectual treatment 
will be a sinapism, and next a vesicatory to the epigastrium, 
with dry frictions, and a lotion to the surface of strong solution 
of alum in brandy, or the hot air-bath. 

As the system emerges from these states of prostration, fever 
may ensue, which is to be treated according to its character. 

TREATMENT OF THE APYREXIA. 

INFLAMMATORY FORM. 

Diversified as are anti-intermittent medicines in other respects, 
they all concur in deriving their curative power in this disease, 
from their adaptedness to subvert the disposition to a renewal of 
that- gastric irritation, which usually constitutes its inceptive 
movement. 

Before the commencement of tonic remedies, the system should 
be prepared for their use. In consequence of a neglect of this 
preparation, the difficulty of cure is enhanced, the intermittent 
is in danger of being converted into a remittent or continued 
fever, relapses are common, with serious organic derangements. 
These preliminary measures are emetic and cathartic evacua- 
tions. The former seem, by breaking up trains of morbid asso- 
ciation, to possess in themselves an anti-periodic power. These 
measures should be avoided, however, in case of inflam- 
mation. 

Venesection, — Should the condition be inflammatory or 
febrile. 



INTERMITTENT FEVER. 39 

Topical Bleeding at the epigastrium, should the stomach 
show symptoms of phlogosis, or whenever tonics are not well 
borne. These topical means are of themselves enough, some- 
times, to effect a cure. Phlogosis being manifested, evacuants 
of the alimentary canal should be anticipated by bloodletting. 

Cinchona. — The preparatory means having been taken, the 
most useful of all means is cinchona, or its preparations. With 
the Peruvian bark, it is very advantageous to combine the ad- 
ministration of certain other articles — as cloves, tartrate of pot- 
ash, muriate of ammonia, or carbonate of potash or soda, in 
the proportion of a drachm to the ounce. 

R. — Pulv. cort. Peruv. 3ss. 
Rad. serpent. 3j. 
Sod. carb., vel potass, carb. Bij. 
Div. in pulv. iv. The whole to be taken in the course of the day. 

R. — Pulv. cinchon. 3j. 
Confect. opii 3j. 
Succ. limon. 3ss., vel 
Acid, sulph. aromat. 3j. 
Vin. Lusitan. rub. 3viij. 
Given in the dose of a wineglassful, three times a day. 

Sulphate of Q ni nine. — Recommended as a substitute for 
the bark, from its being more tolerable to the stomach. Its 
cures, however, Dr. Chapman thinks, though rapid, are not the 
most radical. Bad effects follow its exorbitant use. It is best 
given in the dose of a grain every hour, commencing early in 
the morning, fasting, and ending at the time of the expected pa- 
roxysm. Most efficacious is it in solution, combined with the 
sweet spirits of nitre, or opium. When necessary, from phlo- 
gosis of the stomach, or other cause, it may be applied endermi- 
cally. Five or six grains of the sulphate applied once in twenty- 
four hours, are alleged to be sufficient. It should be mixed with 
cerate. The acetate is less x irritating. Quinine and the bark 
failing, 

Arsenious Acid, or Fowler's solution, may be tried. 

Sulphate of Copper, excellent in inveterate cases, espe- 
cially of quartan type. 



40 DISEASES OF THE CIRCULATORY SYSTEM. 

Dr. Chapman regards the last two articles as superior to 
quinine in chronic cases, and also as respects completeness and 
permanency of cure. 

A vast number of other remedies have been recommended, 
stimulant, tonic, or astringent. 

Indeed, whatever powerfully affects the physical or mental 
constitution, has a tendency to destroy the intermittent. 

CONGESTIVE FORM. 

The Bark, or Quinine, is to be largely given in conjunc- 
tion with tonics, or even diffusible stimulants. 

The tonics may, in these pernicious intermittents, be employed 
in the paroxysm, according to circumstances. The indications 
for their use are the same with those belonging to the same con- 
ditions of remittent and continued fevers. 

TREATMENT OF ANORMAL MANIFESTATIONS. 

In intermittent developing itself merely on some organ, the 
eye for instance, or as a nervous disease, the treatment will be 
the same as in a normal presentation. 

Intermittents being blended with a more serious disease, as 
dysentery, should be disregarded till the more urgent affections 
be cured. 

TREATMENT OF CHRONIC INTERMITTENT. 

This, if dependent on visceral phlogosis, must be subverted 
by remedies adapted to the reduction of the phlogosis. Should 
there be also obstruction, some alterative, especially mercury, 
should be employed. Kept up by habit, a blister on the epigas- 
trium, may be used. Emetics may be employed for the same 
purpose, when there is certainly no inflammation. The bark 
may be well employed, when there is no phlogosis, but when 
there is, it is highly pernicious. Arsenic and copper are some- 
times better, however, than bark. 

When an intermittent has been long dormant, and is re-deve- 
loped in the winter, for instance, by the supervention of one of 



INTERMITTENT FEVER. 41 

the phlegmasia, the primary treatment should be addressed to 
the phlegmasia. But this being cured, and the intermittent re- 
maining, recourse may be had to bark, or other tonics. 

DIE T. — This should co-operate with the treatment, and be 
more or less nutritious, accordingly. 

Intermittents, though some have attempted to prove them to 
be salutary, should be cured as soon as possible. It is not true, 
moreover, that they have much tendency to cease spontaneously. 
The earlier, too, we commence with tonics, after the evacuant 
preparation, the better. 

Intermittents have a tendency to be revived every seven days. 
In anticipation of this, therefore, we should administer our tonics, 
for three different periods. 

In consideration of the great disposition of the disease to re- 
turn, even when seemingly eradicated, all exciting causes ought 
to be avoided. If the patient do not emigrate from the miasma- 
tic district, he should be particularly careful not to go out in the 
morning without having first eaten, and should take daily doses 
of quinine alone, or with iron. The cold bath or travelling often 
succeed in preventing relapses. An attack being threatened, 
the patient should go instantly to bed, cover himself warmly, and 
take an opiate. But as a preventive of a paroxysm of the perni- 
cious congestive intermittent, so much dreaded, the most effica- 
cious appliance is a blister to the epigastrium, so as to be fully 
drawing at the time of the expected accession. At this juncture, 
also, is to be given the following mixture: 

R. — Sulph. Quinice gr. viij. 
Sp. iEtber. Nitr. 3j. 
Tinct. Opii gtts. xxv. 
Aq. Font. gj. 



FEBRIS REMITTEES Oil REMITTENT FEVER. 



This is a fever, which, though observant of somewhat regu- 
lar exacerbations and abatements, never wholly subsides like an 
intermittent. 

Remittence is common to many febrile conditions; but in the 
one now in view, commonly called the autumnal bilious remit- 
tent, it forms a striking characteristic. Endemic to hot countries, 
it is seldom met with even in temperate regions. 

It will be here described as it occurs in our own country. It 
is more pervading and severe in the southern and southwestern 
portions, in miasmatic districts, and particularly when intense 
heats succeed heavy rains. By no length of residence, in some 
places at least, is the protection of acclimation acquired, except 
by the negro, on whom it seems to be partially conferred. 

It appears in the South as early as the first of June, though 
it seldom shows itself w 7 ith us before the close of August. It 
is rarely seen in large cities, except on their confines. 



- SYMPTOMS OF THE INFLAMMATORY FORM. 

FORMING STAGE. — Anorexia, languor, heaviness, and 
anxiety, alternate sense of heat and cold, obtuse pain in the 
head, back, and limbs. 

CHILL. — This is sometimes absent. It is generally slight, 
though it may be otherwise. 

F E V E R. — Increased pain in the head and back ; swimming, 
inebriated-looking eyes ; prascordial tightness; heat, general or 
partial ; vomiting of bilious or other matters ; a white slimy or 



REMITTENT FEVER. 43 

yellowish furred tongue; thirst, bitter taste, a feeling of burn- 
ing, distension, or pain in the stomach ; tender epigastrium ; 
torpid bowels, unless they be involved in the affection ; some- 
times sallowness of the skin and eyes, and a strong, rapid, 
tense, and voluminous pulse. During the twenty-four hours, 
and especially in the morning, a remission is observed. The 
renewed attack is rarely preceded by a chill. As the case 
proceeds, if the attack be severe, the type changes from quoti- 
dian to the tertian. 

The fever having progressed uninterruptedly beyond the 
fifth, and sometimes the third day, we shall find the vital powers 
depressed, and augmented cerebral and nervous affection. 

Dr. Chapman believes there is a disposition in the disease to 
observe in its solution the septennary period. 

CAUSES. 

R E M T E. — Cenuine remittents arise only from miasmata. 

E X C I T I N 6. — Indiscretions in diet, exposures to the heat of 
the sun, or to night air, indulgence of perturbating passions, &c. 

DIAGNOSIS. 

Remittent is distinguished by the season of the year, the 
locality, the force of the attack, the distress of the stomach, the 
state of the tongue, sallowness of the skin and eyes, and, above 
all, by the tendency to remission. 

PROGNOSIS. 

F A V U R A B I E SYMPTOM S.— Remissions regular, and in- 
creasing in length; soft and slow pulse; skin moist, relaxed, 
temperate, and of a natural colour; stomach quiet; the tongue 
cleaning and a cessation of thirst ; the alvine discharges being 
of bile, or dark, tarry, and fetid ; urine lateritious or turbid, with 
copious precipitates ; scabby eruptions about the mouth ; ra- 
tional mind, with a firm and steady state of the nervous system. 



44 DISEASES OF THE CIRCULATORY SYSTEM. 

UNFAVOURABLE S Y M P T M S.— Tendency to a typhoid 
state; delirium, or other cerebral or nervous affection; cold 
wrists and warm hands ; gastric distress, watery alvine dis- 
charges, having a cadaverous odour; diminished secretion, or 
suppression of urine : dark and incrusted or flabby tongue ; un- 
natural skin, and fetid breath. 



AUTOPSIC APPEARANCES. 

Mucous coat of stomach, duodenum, ileum, and sometimes 
of colon, is found inflamed. The liver is inflamed and bloated by 
congestion, and generally the gall-bladder is filled with vitiated 
bile. The spleen is disordered chiefly by ramollescence. The 
peritoneum, with the mesenteric glands, is involved. No organ 
suffers more than the brain and its arachnoid membrane. The 
spinal marrow is also affected. The blood, at first presenting a 
dense inflammatory cake, afterwards loses its inflammatory 
appearance, and is nearly destitute of cohesion. 

PATHOLOGY. 

This fever is synochus, with a tendency to typhoid degene- 
ration. Commencing in gastro-enteric irritation, soon converted 
into inflammation, the liver, then commonly the brain, and finally 
the circulatory apparatus, become affected. Connected as the 
stomach and liver are, by functional and other ties, the latter is 
involved in the disease of the former, particularly in warm wea- 
ther, when there is a predisposition to hepatic disorder. The 
liver at first being merely irritated, an excessive biliary secretion 
takes place. From over-stimulation, it afterwards becomes 
torpid, congested, inflamed, and secretes not at all, or very im- 
perfectly. Now the skin and adnata become icterose, which 
denotes not the exuberance, but the want of bile. The change 
of colour is shown, under the head of Jaundice, to result from 
a peculiar condition of the capillaries, sympathetic of gastro- 
hepatic irritation. Sometimes the heart and blood-vessels sym- 
pathize with the stomach, inducing fever, before the implication 
of other structures. So much do the affections of the various 



REMITTENT FEVER. 45 

organs fluctuate in intensity, that in different stages of the dis- 
ease the most opposite titles are conferred upon it — that being 
called cerebral fever, which before was hepatic, and was pri- 
marily gastro-enteric fever. 

TREATMENT. 

First discover to what height the fever has progressed, and 
what is the principal seat of the affection. 

FORMING STAGE OF THE FEVER.— Here we have gastric 

irritation, headache, and slight disorder of circulation. The 
remedies are, gentle evacuation of the primae vise, leeches to the 
epigastrium, cold to the head, a stimulating pediluvium, cold 
demulcent drinks, tepid or cold sponging, mild diaphoretics, as 
the neutral mixture, with rest and extreme abstinence. 

FEVER FULLY FORMED. Venesection.— When there is 
a strong, full, or active pulse, a hot skin, or determination to 
the brain, or other important organs, this is unrivalled. With 
such indications, bleeding will never be amiss. In these fevers, 
with a vigorous constitution, bleeding should be rapid and 
carried to the verge of syncope, or to syncope itself. Small 
bleedings merely moderate the disease ; large ones make such 
an impression upon the capillaries as to subvert it. The force 
of general vascular action having been reduced, venesection 
need hardly be repeated. 

Local Bloodletting, especially to the head and epigas- 
trium. 

Cold Applications to the head. Sometimes they are 
well applied to the epigastrium. But to the latter region, 
fomentations are generally preferable. 

Stimulating Pcdiluvia occasionally, as revulsives. The 
extremities are always to be kept warm. 

Purgatives. — The case having been thus prepared, the 
bowels are to be cleansed of the morbid secretions of their 
mucous coat and the liver. Thus a great source of irritation is 



46 DISEASES OF THE CIRCULATORY SYSTEM. 

removed. Dr. Chapman employs calomel, followed by castor 
oil, or Epsom salts. 

Emetics. — Very salutary, as well from their tendency to 
equalize the circulation and restore healthy secretion, as from 
the evacuation of the stomach. But they must be used only 
before the accession of gastritis, or after its reduction. Gastritis 
is to be determined by the tongue, which is either milky white, 
or dark in the centre, with florid edges ; by tenderness of epi- 
gastrium on pressure ; sense of heat in the stomach ; violent 
retchings, with the evacuation of a glairy fluid ; and above all 
by extreme jactitation. It is best, however, for the inexperienced 
practitioner to forbear emetics, unless clearly demanded, and 
to substitute purging, which acts on nearly the same principles. 
Evacuants should, if possible, be given only during a remission 
of the fever. 

Laxatives, — A recurrence to cathartics, will seldom be de- 
manded; but moderate doses of calomel, or the blue pill, to 
promote or correct secretion, and remove undue accumulations, 
or an occasional dose of castor oil, will prove useful. We may 
also co-operate with enemata. 

By the evacuants above-mentioned, will we succeed in pro- 
ducing dark, tarry, fetid, acrid stools, glutinous in character, 
which had formed on the bowels like an adventitious membrane. 
Their removal is both beneficial in itself, and indicative of a 
prior improvement. 

Mercury, when given moderately, purges ; given very largely, 
it creates torpor by excess of stimulation ; given minutely, it 
acts specifically in the revival or correction of secretory power. 
We see, then, how it may be abused in the administration of 
excessive doses. If in such doses it should purge, it purges only 
by watery stools with great irritation. But such stools are of 
no value here. 

But evacuations may be carried too far. By undue irritation 
of the bowels, in this way, an artificial dysentery is effected, 
with tender, tympanitic abdomen, florid, or heavily furred 
tongue, and . much cerebral disturbance. Whenever watery 
discharges succeed dark, tarry ones, we should desist from 



REMITTENT FEVER. 47 

purgatives, and give only emollient enemata, or use other mea- 
sures to allay intestinal irritation. 

SUBSIDIARY MEASURES. 

Cold Sponging. — Very soothing and useful, when the 
skin is steadily hot and dry, and the pulse vigorous. 

Enemata of Cold Water, often repeated, under like cir- 
cumstances, are, perhaps, still more serviceable. They should 
not be used in loaded bowels. 

A n t i m n i a 1 s, — The best of these is tartar emetic. It should 
be given so as not to produce nausea. Where the tartar emetic 
is not borne by the stomach, we may substitute the effervescing 
draught. 

Blisters. — Applied when vascular action is high, they 
aggravate the fever and inflammation ; but the action having 
been reduced, they contribute much to the complete destruction 
of inflammation. They also alter the condition of the capilla- 
ries, so as to effect a perspiration which had been obstinately 
refused before. They should be retained so as merely to pro- 
duce redness, the part being then dressed with a poultice, or 
simple cerate. 

Bar k. — This may be given when the case is lingering, feeble, 
and endued with decided paroxysmal manifestations. The 
tongue, too, must be moist, the surface cool, relaxed, and per- 
spirable, and there must be no marked local affection. Given 
otherwise, it is apt to cause a typhoid degeneration. Sulphate 
of quinine, however, is by high authority said to answer when 
the bark will not — as, where the skin is dry. 

But when the disease has taken a decidedly intermittent type, 
then the quinine is, undoubtedly, of prime value. 

The mercurial impression cannot be produced in the height of 
the fever, and is not needed when it has subsided. The mer- 
curial action is the effect, and not the cause of the improvement. 
Dr. Chapman limits the use of mercury, as has been seen, to 
a purge at first, and to small doses subsequently, designed to act 
upon the secretions. 

In southern remittents, where the hepatic congestion is 
greater, somewhat larger doses may be required for the relief 



48 DISEASES OF THE CIRCULATORY SYSTEM. 

of the liver. Yet he deprecates the absurd and injurious ex- 
cesses so much practised. Such exhibitions of mercury can 
be vindicated by no circumstances, and they frequently entail 
the most deplorable results. 

The condition which is liable to supervene in the advanced 
stages, by the giving way of the vital powers, being the same, 
essentially, with a certain phase of typhus fever, will be treated 
of under that head. 



CONTINUED FEVERS. 



This term is applied to fevers, which have a slight daily re- 
mission. Dr. Chapman is persuaded, that, excepting the brief 
febrile irritations denominated ephemera, and perhaps the yellow 
fever, either of which is scarcely a genuine form of pyrexia, 
every fever, for a certain period at least, is made up of parox- 
ysms. Continued fevers arising from marsh miasmata, show 
an inclination to observe some one of the various primitive 
intermittent types, — some inclining to the quotidian, others to 
the tertian, and others to the quartan. 

The term, continued, is used, therefore, in a qualified sense. 

Of these fevers, the most common is a congestive and more 
continued state of the autumnal remittent which has been just 
disposed of. 

TYPHUS, derived from the Greek rvcpts (tuphos), signifying 
stupor, is the old and familiar title of such fevers. But from 
the disease being thus designated by a symptom not always 
present, and from the very ominous import of the term, it would 
be well, if by general consent it could be abandoned. 

Congestive is used here in a sense contradistinguished to in- 
flammatory, or rather as the antecedent stage of the latter in a 
weakened form. These terms applied to the doctrine of fever, 
are not very significant ; but in the present state of our know- 
ledge, what better can be substituted ? There exists, often, con- 
gestion in one organ, cotemporaneously with inflammation in 
another. » 

Typhus is commonly divided into the typhus mitior, and 
gravior, corresponding respectively to the old terms, nervous, 
and putrid fevers, and with the French ataxic, and adynamic. 

4 



50 DISEASES OF THE CIRCULATORY SYSTEM. 

Dr. Chapman divides the fever, according to its degree of 
severity, into three grades, — the mild, the intermediate, and the 
severe. It is considered essentially congestive. 

SYMPTOMS OF THE MILD FORM. 

PREMONITORY.— The approach is often very mild and in- 
sidious. A mere feeling of uneasiness, for days ; or languor 
with low spirits, hebetude of mind, and giddiness. Next, in- 
creased weakness ; anorexia, or sickness of stomach ; costive- 
ness, or diarrhoea ; furred tongue, which is flat and flabby ; 
soreness of the muscles ; uneasiness, or pain in the head, neck, 
or back, or in all these parts ; with an alternation of chills and 
flushes, the pulse being rather irritated. 

FEVER DEVELOPE D— Augmentation of cerebral disorder, 
evinced by vertigo, or headache, or delirium ; dulness of hear- 
ing, and general insensibility to impressions ; the voice falter- 
ing ; the eye inexpressive ; subsultus tendinum, and muscular 
tremors. 

THE CASE EXASPERATED— Tongue florid and polished, 
or, perhaps oftener, partially coated or darkly encrusted, tre- 
mulous and not always easy of protrusion ; torpor of bowels, 
or excessive purging of thin, acrid fluids ; meteorism, with 
tenderness of the abdomen ; urine scanty and highly coloured ; 
in cold weather, (and rarely at other times,) some acute 
affection of the lungs ; skin usually dry and hot, or the tem- 
perature unequally diffused ; an occasional eruption on portions 
of the body, either miliary or of larger vesicles, with inter- 
vening redness, and technically called sudamina. Conjointly 
or separately, with the sudamina, are sometimes found rose- 
coloured spots. Pulse variable. Mostly it is full and soft, be- 
coming small, weak, and exceedingly accelerated — though Dr. 
Chapman has seen it throughout slow and hobbling, indicative 
of a very obstructed circulation. In this way, especially under 
bad practice, does the fever run on for several weeks, or 
degenerates into a more violent form. 



CONTINUED FEVERS. 51 

SYMPTOMS OF THE INTERMEDIATE 
FORM. 

PREMONITOR Y— Much the same as in the mild form. May 
simulate at first an intermittent. 

FEVER BEING FULLY DEVELOPED.— Well-defined py- 
rexia ; heat of surface ; considerable determination of blood to 
the head, with a tendency to delirium ; heaviness, or stupor ; 
tongue thickly furred, or covered with a white slime, or more 
or less dry ; peculiar countenance, the eyes being suffused and 
dull, or swimming and fatuous, as in incipient inebriety, or the 
aspect being scowling and malignant, or expressive of distress j 
pulse generally full and slow, though very compressible, denoting 
much disturbance of the animal economy ; breathing irregular, 
with deep sighing, and the breath sometimes very offensive ; 
bowels costive ; heat, oppression, and tenderness of the stomach, 
with occasional vomitings of bile, or glairy, viscid matter, and 
often unquenchable thirst. Sometimes purging early com- 
mences. 

SYMPTOMS OF THE EXTREME FORM. 

THE CASE ADVANCING, these symptoms are aggravated. 
The aspect livid, bloated, smooth and polished, or pale and col- 
lapsed, with the eyes sunken and heavy, covered, as it were, 
with a film. Coma, with low delirium; inarticulate utterance, 
or vehement ravings, or typhomania, or distraction of the senses 
denoted by floccitation or picking at the bed-clothes, or catch- 
ing at illusory objects (called muscse volitantes), or pouting of 
the lips. The fever continues, though the pulse is smaller, and 
so quick as scarcely to be counted, or, where the brain is deeply 
implicated, preternaturally slow. Tongue is now usually dry, 
dark, encrusted and chapped, tremulous, and hardly capable of 
protrusion, and the gums and teeth covered with the same tena- 
cious sordes ; temperature unequally distributed, the extremities 



52 DISEASES OF THE CIRCULATORY SYSTEM. 

being cold ; nervous tremors, a prominent symptom from the 
beginning, increased so as to constitute subsultus tendinum. 
The tendon may be thrown by the spasm over the radial artery. 
Convulsions may occur, or oftener rigidity of the extremities of 
one side. Abdomen commonly tympanitic, and the bowels, 
though previously torpid, discharge involuntarily large quanti- 
ties of sooty fluid. Urine is deeply coloured and offensive, or 
pellucid, or its secretion is entirely suspended. 

In the highest degree of malignity, we have glandular ab- 
scesses, haemorrhages of black dissolved blood from the various 
mucous membranes, with vibices and petechias, and purpura or 
large livid spots. The pulse sinks, skin is universally cold, with 
a clammy sweat, singultus occurs with vomiting of a dark fluid, 
and death closes the scene. 

This description characterizes a case of extraordinary malig- 
nity. Yet the fever may present great variety in intensity and 
complication. 

This form of fever may terminate in two or three days by 
convulsions, from congestion of the brain, or may run on for 
two or three weeks or longer. Average duration from eight 
to ten days. 

The severe form just described, is rarely seen in this country. 

Fevers, however, usually sporadic or endemic, though some- 
times epidemic, occur among us of an infinitely more congestive 
character. They occur generally in the autumn. The system 
may sink at once into a collapse from which it never emerges. 

More frequently commencing with extreme muscular debility, 
the disease is displayed in a rapid succession of chills and 
flushes, the skin soon becoming permanently cold, pallid, or 
mottled and shrivelled. The face, in a violent attack, quickly 
becomes dusky red, leaden, or bronzed; the forehead smooth 
and polished, the eyes wild, glassy, and vacant; the aspect ex- 
pressive of great distress; the brain always much affected. The 
alimentary canal and liver suffer, especially in warm weather, 
or where the foundation of the disease has been laid in mias- 
matic influence. In w inter the lungs are more apt to be involved, 



CONTINUED FEVERS. 53 

the cases then, from the livid patches on the skin, being called 
the spotted fever, or, from the lowness of animal temperature, 
the cold plague. 

CAUSES. 

PREDISPOSING. — Is the fever generated by contagion? 
Dr. Chapman is much inclined to doubt it, but thinks it safest to 
consider the subject as still sub judice. Let it be understood, that 
by contagion is meant a virus secreted by the capillaries, which 
is capable of reproducing the same disease. The advocates of 
contagion adduce many instances of typhus fever attacking a 
great number of individuals collected in the same building, and 
instances to show that the disease is carried by fomites, many 
of which citations are indisputably authentic. It appears that, 
the fomites are sometimes very retentive ; retaining, in a case 
adduced by M'Cormac, the semina of the fever, for a space of 
two years. But generally their influence is very much confined. 
Dirty clothes seem to be better vehicles for this infection, than 
clean ones. The disease arising from fomites is said to be the 
most malignant. Of this infection the incubative period is gene- 
rally eight or ten days, though the fever is sometimes manifested 
almost immediately, and at others, not for seventy days. The 
facts to prove these statements are multiplied and conclusive. 

But, after all, what is there in facts of this kind to demon- 
strate that the agency employed in the propagation of the fever, 
is an animal secretion ? They may all be otherwise explained. 
The fever seems to have been always generated primarily in 
close, crowded quarters, where are evidently means enough for 
its origination. And if it be possible that virus sufficient for the 
infection of one individual should be thus spontaneously gene- 
rated, why should not all be deemed to be affected from the same 
source? And why, again, may not this virus be carried by fo- 
mites as readily as that which is supposed to be contagion? The 
doctrine of contagion, then, must fall before a simpler explana- 
tion of facts, not from positive disproof, nor from a want of ana- 
logies, but from the want of positive proof. 

Conceding, however, every thing to the contagionists, which 



54 DISEASES OF THE CIRCULATORY SYSTEM. 

is claimed by them, it must be confessed that congestive or 
typhus fevers do also arise from other causes. Among these, 
may be a want of oxygen, or excess of carbonic acid, or other 
vitiation of atmosphere effected in crowded assemblies. The 
bad cerebral and nervous effects of such assemblies are directly 
evinced by headache, tremulousness, nausea, embarrassed respi- 
ration, muscular relaxation, and loss of strength. The disease 
is owing, also, to penurious diet, miasmata, to extreme heat, or 
extreme cold. It is found, therefore, in reference to the last two 
causes, most in Winter in the North, and most in Summer in the 
South. Typhus is attributable, also, Dr. Chapman thinks, to in- 
adequate evacuations, or a too early resort to stimulants in other 
fevers. 

E X C I T I N G. — Anxiety or grief, especially nostalgia or home- 
sickness. In fine, whatever greatly depresses the mental or 

physical system. 

DIAGNOSIS. 

Pre-eminently discriminative, is sensorial and nervous disturb- 
ance, with simultaneous loss of muscular strength, epigastric 
and precordial discomfort. From the beginning, prevail despon- 
dency and listlessness of mind and body. The dulness of appre- 
hension, thickness of speech, tottering gait, and pallid or mottled, 
or dusky red hue, are also diagnostic symptoms. As the fever 
developes itself, however, all obscurity must cease. 

Being caused by contagion, or malaria, the cerebral and 
nervous symptoms are exceedingly prominent, the pulse is 
rather irritated than oppressed, the fever is less congestive in 
character, slower, and seldom or never appears in warm 
weather. Being caused by continued heat and miasmata, it 
begins with a chill, and is of paroxysmal tendency, with pre- 
dominant implication of the chylopoietic apparatus. Occa- 
sioned by cold, it is sudden in accession, with a protracted 
collapse, and on reaction there is especial implication of the 
pulmonary organs and nervous system, with sometimes an 
affection of the liver or spleen. There is nothing distinctive of 



CONTINUED FEVERS. 55 

dothinenteritis, — the alleged marks of that affection being com- 
mon to other forms of disease. 



PROGNOSIS. 

The fever being brought on by contagion, or foul air, runs a 
protracted and obstinate course, and our chief merit consists in 
merely rescuing important organs from serious lesion, until the 
fever spontaneously subsides. Should the patient be retained in 
a foul atmosphere, the chance of cure is diminished. In the 
typhus fever of the United States there is nearly always the 
critical tendency, with a disposition to subside spontaneously 
at an early period, and to submit to remedial impressions, 
unless there be extreme congestion, with little capacity of reac- 
tion ; which condition proves very difficult of removal. Epi- 
demic typhus is very aggravated and fatal. 

'The favourable symptoms are, abatement of the cerebral and 
nervous affection, cheerfulness, a subsidence of the engorge- 
ments, soft clean tongue, temperate surface, tarry alvine dis- 
charges, heavy depositions in the urine, glandular swellings, 
and scabby eruptions about the mouth. 

The adverse signs are, a sense of internal heat with cold skin, 
or the peculiar heat called color mordax; petechias, ecchy- 
moses, &c. ; great irritability, or preternatural composure of 
the stomach, with a good appetite ; a polished, or dark-coated 
tongue, or one perfectly natural ; pain in the head, nape of 
neck, or lower part of spine; haemorrhages; retention, or 
suspended secretion of urine ; the various cerebral and nervous 
affections; distorted countenance; insensibility to vesicatories 
or sinapisms, or the spots of their application becoming gan- 
grenous ; cadaverous odour; a trembling or hobbling pulse; 
and a disposition to slide down in the bed. 

AUTOPSIC APPEARANCES. 

In the mildest cases not very well known. May be conjec- 
tured from the symptoms to consist in some congestion, with a 
slight phlogosis or erethism of one or more tissues. 



56 DISEASES OF THE CIRCULATORY SYSTEM. 

In severer forms are found injected and thickened arachnoid, 
vascular and turgescent brain, stomach and duodenum inflamed, 
ulcerated, or ecchymosed, or softened ; and the ileum, and in 
case of diarrhoea, the coecum and colon, affected much in the 
same way, even to ulceration. 

According to the observations of Louis, Chomel, and Cru- 
veilhier, ulcerations of the glands of Peyer and Brunner, with 
lesions of the spleen, constitute the most uniform pathological 
characteristic of this fever, so that it has received the title of 
dothinenteritis. But their statements, however true in regard to 
typhous cases in the Parisian hospitals, are not repeated by the 
cultivators of morbid anatomy in Great Britain and Ireland, 
who assert such lesions to be very rare. One of them, Ma- 
crobin, affirms them to be confined to the large and foul 
infirmaries of Paris and London. Dr. Chapman thinks very 
few cases would be found in our own hospitals. 

The glands both of Peyer and Brunner, or either set of them, 
may be alone affected. Those of Peyer are more commonly 
involved. 

The glands enlarge so as to resemble a pimply, or even pus- 
tular eruption. Not being resolved, this state is prone to dege- 
nerate into ulceration. The ulceration may be deep, but is 
commonly trivial. The follicular affection may be inde- 
pendent of inflammation of the mucous tissue, or combined 
with it. 

In cases arising from miasmata, or heat, the liver and spleen 
are congested and softened, and the pancreas sometimes hard- 
ened. The peritoneum and mesenteric glands are also gene- 
rally implicated. The case proceeding from the action of cold, 
lesions of the lungs in substance, and more commonly of the 
pleura and bronchia, are to be found. Affection of the wind- 
pipe sometimes occurs. 

IN MALIGNANT TYPHUS.— The solids are flabby and 
seemingly, though not actually, putrescent; and the blood de- 
prived in a great measure of its solid materials, and with its 
constituents commingled. The viscera are marked by heavy 
congestion, and unless no reaction has taken place, with a weak 



CONTINUED FEVERS. 57 

<*rade of inflammation, in which the spinal cord, ganglia, solar 
plexus, and the nervous filaments derived from it, participate. 

PATHOLOGY. 

Are low fevers, engendered by various causes, identical in 
nature I Bancroft endeavours to prove that there is a specific 
typhus fever, which reproduces itself by contagion, and which 
has existed from time immemorial; and that all low fevers 
generated by other agencies are entirely incapable of originating 
a contagion, and are not specific. Dr. Chapman thinks that 
Bancroft adduces much to sustain his proposition, and that it 
may be hereafter verified. In such a case, other low fevers 
should be called typhoid (typhus-like). 

Louis, and Bretonneau hold the existence of a distinct form of 
low fever, different, however, from the regular typhus, and dis- 
tinguished by follicular lesion. This is called typhoid fever by 
Louis, and dothinenteritis by Bretonneau. That there is a 
fever of a distinct nature, originating in, and kept up by folli- 
cular lesion, Dr. Chapman deems preposterous in itself, and as 
yet gratuitous. How, he asks, can a disease so singularly per- 
vading receive its birth and be nurtured in a source so insig- 
nificant I 

Still more extravagant is the allegation of those who hold that 
the disease itself consists in these lesions. 

The early phenomena of the disease are not at all enteric. 
They are gastric, nervous, and cerebral. Low fevers are 
known to be nearly exempt from such lesions. These generally 
occur in children, among whom low fevers are comparatively 
rare. Conversely is it ascertained, also, that similar lesions 
exist in scarlatina, cholera infantum, diarrhoea, dysentery, tabes 
mesenterica, phthisis pulmonalis, strangulated hernia, and other 
diseases, not of a low type, and not even accompanied with 
fever. Were the fever a peculiar exanthematous one, as some 
contend it is, then, the follicular pustules would be a remote 
effect merely. 

Dr. Chapman, then, deems these lesions to be not the cause, but 
the result of low fever ; and not a constant, but a casual result. 



58 DISEASES OF THE CIRCULATORY SYSTEM. 

Andral has seen well-marked cases of the fever where no 
appreciable alteration of the alimentary canal existed. 

Formerly fevers with petechias were held to be distinct in 
nature. But subsequently were found to derive their petechias 
from hot and badly ventilated apartments, or an alexipharmic 
practice. The same, Dr. Chapman suspects to be predicable of 
the sudamina and rose-coloured blotches, the pretended incidents 
of this dothinenteritis. There is no doubt that neglect of purging 
and other evacuations, has much to do with the production of 
the follicular lesion. 

Dr. Allison, of Edinburgh, treating of fevers, in M Tweedie's 
Practice of Medicine," says that follicular lesion is an occasional 
accompaniment of typhoid fever in Edinburgh, especially during 
an epidemic tendency to diarrhoea or dysentery. That the 
symptoms and local affection are the same with those which 
have attracted so much attention in Paris, but that invariably, 
the follicular lesion is " secondary in point of date," and its ap- 
pearance and disappearance " exert no influence on the essential 
features of the general febrile state." 

The doctrine nowhere receives general adoption. Many of 
its former adherents are giving it up. Louis now believes the 
follicular disease to be merely an effect. 

Dr. Chapman believes that the low fevers, like other diseases, 
are different in nature, from, among other things, a difference in 
the cause. Excepting, however, the typhus seemingly arising 
from contagion, of which he considers that imputed to follicular 
irritation to be merely a modification, he does not think any of 
these fevers acquire such a pathological difference as to mate- 
rially determine the treatment. 

From the external physiognomy of the anatomical characters 
of low fevers, like the inflammatory remittent, we judge that 
they commence in epigastric irritation, which by sympathetic ex- 
tension involves first the brain, thence the nervous system at large, 
and thence various tissues and organs, and the blood itself. But 
the seat of primary irritation may not be always the stomach. 
Dr. Chapman, in cases excited by contagion, or foul air, has 
seen it to exist in the brain, and again in the lungs, &c. 

Essential only to the constitution of the typhous state is a cer- 



CONTINUED FEVERS. 59 

tain kind and degree of sensorial and nervous disorder, which 
nay proceed directly from the brain itself, or may be derivative 
from a reflection of an irritation of any one part of the great 
nervous centres. In typhus mitior, the impression on the ner- 
vous system is moderate, resembling narcotism, the vascular 
system at an early period not being implicated. 

Uniformly the result of an intense degree of such influence 
upon the cerebral and nervous system, is congestion, and by 
which well-marked typhus is characterized. Regarding the 
nature of congestion, it may be stated, that the veins become 
the principal receptacles of the blood, while the arteries are 
comparatively empty. The principal symptoms of internal con- 
gestion, are a cold, pallid, or mottled surface, an emptied pulse, 
or from the struggles of the heart, a full and soft, or inflated 
one, an indisposition of the blood to coagulate, and much op- 
pression attended w 7 ith debility. 

The venous engorgement is attributable to the fact that the 
arteries retain their vitality and energy longer than the veins, 
and consequently the power of emptying themselves when such 
a power is no longer imparted to the veins. So we see, in apo- 
plexy of the brain, or spinal marrow, in the inefficient state of 
the brain and mucous centres just before death, in haemorrhages, 
and in many other diseases, that heavy venous engorgements 
occur. The innervation upon which the contractility of the vas- 
cular system depends, is no longer adequate for the supply of 
the veins. In typhus, this want of innervation results from the 
impression on the brain and nervous system of the remote cause. 

More frequently, however, there is sufficient energy left for 
the institution of a partial reaction, which leads to the deve- 
lopement, in certain parts, of a low form of inflammation. In 
these cases the inflammation is generally found in the surface, 
or investing membrane of a viscus, while congestion exists in 
the interior of the viscus. This presents a mitigated form of 
the fever. 

The blood is discovered to have lost much of its fibrine and 
its solids; and the blood globules are observed to have been 
materially affected. But these changes, though they no doubt 
operate mischievously on the solids, are secondary in their oc- 



(JO DISEASES OF THE CIRCULATORY SYSTEM. 

currence to those main derangements of the solids, which we 
have described. 



TREATMENT. 

MILD FORM. — Of cardinal importance in the treatment of 
typhus is it, that not the name, but the actual pathological con- 
dition, should be prescribed for. What is this condition in 
typhus mitior? There is no great degree of active phlogosis, 
nor weight of engorgement, nor vitiation of the secretory func- 
tions. 

Discarding then venesection, unless demanded by unusual 
vascular force, and emetics and purgatives, and all other harsh 
or vigorous measures, we resort to gentle laxatives and ene- 
mata ; topical bleeding, repeated and diversified, as parts may 
seem to suffer; with cold or tepid sponging of the surface, 
according to the indications, next, to the mild diaphoretics with 
stimulating pediluvia, particularly if the head or primce via) be 
affected, and to the bland mucilaginous beverages, acidulated 
with lemon juice. Still, venesection may be necessary for the 
prevention of a severe developement, and will be then indicated 
by the intensity of the febrile symptoms, and the full and op- 
pressed pulse. 

SEVERER FOR M.— Here, to no inconsiderable extent, are 
congestion and inflammation simultaneously manifested. This 
state, in our country, is commonly connected with the inflam- 
matory remittent fever; — the early treatment being much the 
same, but differing somewhat. 

Emetic s. — Very useful at an early stage by relieving the 
congestion of internal organs, determining to the surface, and 
inducing reaction. Their employment in an advanced stage is 
rather hazardous. They may then be useful, should there be 
much irritation of the stomach from vitiated secretion or other 
contents, but would be very injurious in a gastritis. 

Purging. — Emetics being used or not, purging is early to 
be attended to. Calomel is preferable from its more complete 
•evacuation of the bowels, from its superior power of arousing 



CONTINUED FEVERS. gj 

the recuperative energies, and counteracting the tendency to 
congestion, or relieving its incipient formation, as well as from 
its excellence in restoring, or rectifying secretory action, not to 
mention other salutary effects. 

Venesectio n. — Congestion still existing, or undue febrile 
reaction occurring after the previous evacuations, venesection 
should no longer be postponed. Nay, these conditions being 
pre-eminently marked, it may accompany or precede such eva- 
cuations. 

The quantity of blood abstracted should be such as to over- 
come, or sensibly relieve congestion, taking care not to trans- 
cend the recuperative limit of the system. 

Cups, or Leeches, — Deeming it prudent not to employ ve- 
nesection, we may substitute topical bloodletting, or this may 
be used subsequently to phlebotomy. These applications should 
be made to the seat of the most prominent local affection. 
They are nearly always needed for the epigastrium and head, 
and oftener than is supposed to the spine. A flection of the 
spinal marrow is denoted by pain in the part, and spasm. The 
speedy relief afforded by these means is hardly to be conceived, 
by those who have not witnessed it. They should be renewed 
so long as the condition is unaltered. The point of determina- 
tion is frequently changed, thus requiring of us great vigilance 
to follow it up. 

Subsequent Purgation relieves congestion by revulsion 
to the whole tract of the bowels, removes offensive and de- 
pressing secretions, and is promotive of healthy secretion. It 
is especially useful in our southern fevers. It should not be 
resorted to when activity of phlogosis exists in the bowels, and 
the drastics should be avoided. Calomel, or blue pill, followed 
by castor oil, is to be preferred. A contra-indication is the 
occurrence of thin, watery stools, indicative of increased irrita- 
tion from excessive purging. 

A report upon the post mortem appearances of the bowels in 
cases of this form of disease, by a disciple of Broussais, who 
from theoretical notions was opposed to emesis and efficient 
purgation, describes the alimentary canal as filled with bile 
and other substances, in a state of extreme offensiveness and 



62 DISEASES OF THE CIRCULATORY SYSTEM. 

putrefaction. These cases continued from three to four weeks, 
and they eminently prove the wretchedness of the practice. 

Even the natural contents of the bowels may become irritant, 
as is seen in the occurrence of colic, and enteritis from consti- 
pation. Dr. Chapman thinks it probable, that the dothinenteritis 
is induced, or exasperated, by this want of proper evacuation. 

Cold Applications to the S u r f a c e.— Very useful auxili- 
aries when the skin is heated and unperspirable. It is gene- 
rally safest to sponge. 

With such treatment, the case will, at this time, usually wear 
a favourable aspect. But, in case of increased vascular action, 
or local determination, we should again resort to a general and 
topical abstraction of blood. Now it is that the disease begins 
to grasp important organs, and if its hold be not broken, de- 
plorable derangements of structure will ensue. The disease, 
however, having been mitigated, employment may be made 
of the 

Diaphoretics. — There being still some excitement, the mild 
articles only should be used. Such are the neutral mixture, 
the citrate, or acetate, of ammonia, and sweet spirits of nitre. 
Opium, when admissible, may be added. These not sufficiently 
answering, tartar emetic may be well substituted, in quantities 
not so great as to harass the stomach. Dr. Chapman thinks, 
of all this kind of remedies, the antimonials, perhaps, have the 
greatest power to intercept the march of continued fever. 
Better, however, when the pulmonary apparatus is chiefly con- 
cerned, or when the secretions are defective, or very much 
depraved, is the use of the combination of calomel, opium, and 
ipecacuanha. 

Thus we see that nearly all the remedies by which we 
combat the early stage of this form of typhus, are of the 
depleting or evacuant character, reductive in their tendency, 
or calculated to equalize the circulation, and diminish the heat 
and excitement of the system. 

The mortality resulting from the imbecile treatment of the 
French school has been frightful. Dr. Chapman has had good 
opportunity of comparing the treatment here recommended with 
that by tonics and stimulants, and is convinced of its superiority. 



CONTINUED FEVERS. G3 

Bloodletting is now sanctioned, in Europe, by the most autho- 
ritative writers. Dr. Chapman makes statistical quotations to 
prove the superiority of the plan. Few are the exceptions to 
the rule, that in the early stage of all acute diseases wearing the 
aspect of debility, this must be attributed rather to oppression 
than exhaustion. 

Still, cases there may be, in which, from the overwhelming 
power of the remote cause, the capacity of reaction is eut 
slight, and bleeding should be very cautiously conducted, lest it 
tend only to waste the remaining strength. In these cases the 
pulse forms no guide as to the propriety of venesection. The 
action of the heart, though perhaps more trustworthy, is also fal- 
lacious. Acuteness of pain, warmth of skin, and integrity of 
constitution, are the best indications for the practice. The con- 
firmed drunkard in no disease bears depletion well. Considered 
allowable, venesection is to be tried with the greatest care, and, 
according to the effect, must we stop, or proceed to a iurther 
abstraction. Even then, however, local bleeding may be safely 
and efficaciously performed. Emetics are applicable, especially 
salt or mustard, which do not weaken the tone of the stomach, 
nor depress the vital energy, and are followed by prompt and 
enduring reaction. Calomel, freely exhibited, and at short inter- 
vals, is another important measure. 

These measures failing, resort to sinapisms placed at various 
points, and particularly over the epigastrium. Should so great 
a delay be admissible, a blister to the epigastrium may be sub- 
stituted. This application acts, not only by revulsion to the 
surface, but by a direct relief afforded to the stomach, with 
which, so greatly, the whole economy sympathizes. But still 
more does Dr. Chapman imagine it to act by its influence upon 
the solar plexus and ganglia behind the stomach. It is upon 
the want of innervation, partly, from these centres, that the 
congestion of the viscera depends. From the dependence, also, 
of the respiratory function and the circulation upon the upper 
portion of the spinal marrow, there is an indication for the 
application of a sinapism or blister to the nape of the neck. 

These not answering, bags of hot sand or hot oats, may be 
laid along the body. 



64 DISEASES OF THE CIRCULATORY SYSTEM. 

Concomitantly with these measures, should be administered 
active diaphoretics and warm cordial beverages. 

That powerful stimulants, at this conjuncture, may relieve 
the congestion from torpor, is undeniable ; but, failing, by their 
vis a tergo, they either increase the congestion, or superinduce 
inflammation. The better plan is to precede their use by deple- 
tion, or stimulate and bleed simultaneously. But in cases of 
absolute sinking, stimulation is unconditionally and immediately 
required. Then may be given ether, carbonate of ammonia, 
camphor, hot toddy ; or, should the disease have a miasmatic 
origin, quinine and opium, combined, will be found singularly 
adapted. Such urgent cases, however, seldom appear. The 
system having recovered, under these external and internal 
stimulants, the means formerly mentioned should then be tried, 
namely, bloodletting, vesication, mercurial purging, &c, and, 
subsequently, calomel, opium, and ipecacuanha. 

TREATMENT OF THE STAGE OF EXHAUSTION. 

Little does it matter what may have been the incipient nature 
of the fever, inflammatory or congestive; from the neglect of 
proper evacuations, from the premature use of stimulants, and 
from bad ventilation, the case may fall into a state of exhaus- 
tion. A man in perfect health could, by the same means, be 
reduced in a short time to the same condition. From the com- 
parative inattention of nearly all authors to this subject, it is 
dwelt upon by Dr. Chapman, the more minutely. 

Nothing perhaps in the exercise of our profession is more 
difficult than to discriminate the period at which, in an acute 
disease, stimulants may be advantageously used. Judging from 
the pulse, tongue, skin, topical pain, &c, we perhaps make up 
our mind to try them. But their effect must be most closely 
watched. Being ill-timed, they produce pain in the head, 
morbid vigilance, or delirious wandering, or stricture of the 
chest, jactitation, hot, dry skin, parched tongue, thirst, disor- 
dered stomach, a quick, small, corded pulse, and vitiated secre- 
tions. Unless they act upon one of the secretions, they gene- 
rally raise a febrile commotion. As a common rule, stimulants 



CONTINUED FEVERS. (55 

are not to bo given, when there is reason to believe in the 
existence of inflammation, especially of the stomach or brain. 

Deciding on the use of stimulants, the following may be 
resorted to. — 

Carbonate of Ammonia. — No other stimulant will an- 
swer so well, or is so generally approved of. From the 
action upon the skin and other secretory organs, it may be used 
with less dread in equivocal conditions. It should be given in 
small quantities, and be frequently repeated. Over-stimulation is 
much t% be guarded against. Admirably co-operative with this 
medicine is wine whey. They are generally prescribed together. 
The effect, however, of the carbonate of ammonia wearing off, 
as is speedily the case, with all the diffusible stimuli, recourse 
may be had to 

Camphor. — Dr. Chapman has always used it in connexion 
with opium and ipecacuanha, and rather doubts its utility when 
used alone. 

Vapour Bath, — To be used if the skin is cold or dry, or 
the temperature unequally diffused. The production of a halitus 
from the skin is preferable to a sweat, — the good effect resulting 
from the change in the condition of the capillaries. Should 
the vapour bath stimulate too highly, and create jactitation, 
we should substitute sponging with tepid vinegar, or spirits and 
water, which often has the best effects. 

Epispastics. — Cotemporaneously, or antecedently to the 
course just mentioned, should be used the epispastics, which not 
being called for by local affection, should be applied to the 
extremities. Dr. Chapman, by retaining them only to the pro- 
duction of rubescence, avoids strangury, sloughing ulcers, and 
other detriments. 

The Sulphate of Quinine.— An excellent remedy, and 
particularly useful, when the disease is of a miasmatic source, 
or shows a tendency to remission. 

A new stage of the disease now calls for a new class of means. 

Opium. — Used in small doses, it is a general stimulant, but 
its chief value consists in the relief of low delirium, nervous 
tremors, subsultus tendinum, mental and corporeal distress 
induced by morbid vigilance, anxiety, and restlessness : and 

5 



66 DISEASES OF THE CIRCULATORY SYSTEM. 

the relief of diarrhoea. In these cases it may be more freely or 
largely applied. For the soothing of sensorial and nervous 
agitation the acetate of morphia, or acetous tincture of opium, 
or camphor, is very well qualified. 

Musk, Assafcetida, Castor. — Not so good as opiates, 
but may be substituted for a change. The musk, when pure, 
which it hardly ever is, is excellent. 

Win e. — As a cordial and nutritive stimulant, the best. When 
pure, Madeira and Sherry are to be preferred. Claret may be 
also used. The quantity should be small at first, to be increased 
according to the diminution of susceptibility. 

Carbonic Acid. — To this practitioners were led by the 
notion of its tending to counteract the tendency to putridity. 
But in the living state, putridity never takes place, nor is there 
any tendency to it. The putrefaction of bodies covered with 
petechias, &c, is the slowest. The carbonic acid, however, is 
a cordial and agreeable stimulant to the stomach. It may be 
taken in porter, ale, cider, or champagne wine. 

The mineral acids are remedies of moderate value, and best 
suited to the hemorrhagic condition. 

At this period some practitioners trust to the mere use of 
mercury. This, Dr. Chapman regards as absurd. He uses it 
only with opium and ipecacuanha. 

Oil of Turpentine. — Excellent as a stimulant and as a 
corrective of the secretions of the alimentary canal. It is well 
suited to haemorrhagic cases. 

Dr. Stephens has published accounts of the wonderful success 
of the saline treatment. This he connects with the theory of 
fever being essentially a humoral disease, in which the salts of 
the blood are deficient. But his accounts bear the stamp of 
enthusiasm and exaggeration. The saline treatment, on a simi- 
lar theory, was tried unsuccessfully in the Asiatic cholera. 

These remedies, which we have mentioned, having failed, they 
must be repeated in augmented doses. Phosphorus, a potent 
stimulant, might here be used. But great care in this, as in 
other cases, is requisite, lest, in the enfeebled state of the sto- 
mach, the medicine act upon it chemically. 

Blisters here do no good, and may eventuate in gangrene. 



CONTINUED FEVERS. 67 

But friction over the whole surface with the oil of turpentine 
and olive oil, or other stimulant, are sometimes serviceable. 
Such also is the application of warmth. 

The patient being unable to swallow, administer medicines 
by the oesophagus tube, by the rectum, or by a new surface. 
Dr. Chapman thinks in the advanced stages that it would be 
always better to administer our medicines by injection, the 
rectum then presenting a more susceptible surface than the 
stomach. 

Sometimes a cure is effected, when the case seems desperate. 

TREATMENT OF INCIDENTAL AFFECTIONS. 

1. Determination to the head, with delirium, or stupor, or a ten- 
dency to it. Arising from inflammation, the hair should be cut 
off, and cold applications made to the scalp. These failing, 
resort to topical bleeding, stimulants to the lower extremities, 
and a blister to the nape of the neck. Arising from congestion, 
these remedies are equally applicable, excepting the cold. But 
in an advanced stage, from whichever condition the affection 
may proceed, Dr. Chapman relies most upon opiates, camphor, 
musk and assafcetida, &c. These are as well suited to nervous 
tremors, &c, and even to convulsions. 

2. Restlessness and want of sleep. — In the early stage, when 
these affections are usually associated with increased heat of 
skin, cold to the surface is most tranquillizing. After the force 
of action is reduced, opiates may be properly prescribed. 

3. Excessive nausea, or vomiting. Proceeding from ingesta 
or accumulations of bile, or more offensive matter, which may 
be known from the character of the ejections, it will be neces- 
sary to repeat the emetic, to administer tepid water, or to purge 
with calomel, Epsom salts, or magnesia. Proceeding from mere 
irritability, use may be made of effervescent draughts; lime- 
water and milk, or milk alone, or other alkalies; small portions 
of calomel with a little morphia; mint tea; strong' coffee, with- 
out cream or sugar; acetate of lead, in small quantities; prussic 
acid; the spices; the clove bag, wrung out of hot brandy, to 
the epigastrium, or sinapism or blister to the same region, with 



68 DISEASES OF THE CIRCULATORY SYSTEM. 

stimulant pediluvia. Before trying any of these, we should be 
sure there is no gastritis. In this case, topical bleeding should 
be repeatedly employed, with cold or warm applications, and 
finally a blister. 

4. Diarrhoea. — Supervening in an advanced stage, to be 
treated by astringents, opiates, and the cretaceous preparations. 

5. Haemorrhage. — Sulphate of quinine largely given, the mine- 
ral acids, oil of turpentine, and perhaps phosphorus. 

6. Diminished urination, at an early stage. Topical bleeding, 
counter-irritation, and the mild diuretics. Retained urine must 
be drawn off by the catheter. Contraction of the bladder may 
be sometimes induced by cold or hot applications to the pubes 
and perineum. 

7. Meteorism. — Carminatives useless. Castor oil and oil of 
turpentine, with injections of the latter, or of assafoetida, promise 
most. 

8. Singultus, or hiccup. — Being occasioned by irritation of 
the phrenic nerve, at an early stage, it is relieved by cupping, 
and a blister to the back of the neck. Occasioned by irritating 
sordes in the stomach, it is palliated or removed by alkalies, or 
acids, or by ether, Hoffman's anodyne, or other antispasmodics. 

DRINKS. — A moderate quantity of liquid may be allowed. 
Acidulated drinks, or barley water, rennet whey, &c. In active 
phlogosis of the stomach, iced water, or ice itself, may be amply 
given. The thirst may also be quenched by enemata of cold 
water. The tastes of the patient may be much consulted. The 
mouth should be cleaned with lemon juice, or yeast, or charcoal 
and water. 

FOOD. — The drinks will be sufficiently nourishing, except 
when tonics and stimulants are indicated, and then the diet may 
be changed to co-operate with those measures. The morbid 
and ill-boding appetite, sometimes manifested, should not be 
indulged. 

LIGHT AND C M P A N Y, and whatever accelerates the pulse, 
should be particularly excluded. 



CONTINUED FEVERS. (59 

VENTILATIO N. — Highly important in typhus. Cleanliness 
equally so. The linen to be daily renewed. Unpleasant effluvia 
to be avoided by sprinkling vinegar or cologne-water, or by 
muriatic or chlorine fumigations. Dr. Chapman doubts the 
anti-contagious power of such articles as the two last, but thinks 
them, at all events, generally inapplicable from the oppression 
they cause the patient. 

The disposition of the patient to get up, should be opposed. 
In an old case, however, and where the febrile action is much 
reduced, much benefit may accrue from sitting up, and from 
passive exercise. 

CONVALESCENCE. 

In some fevers there is a great disposition to relapse. 

In the first place, then, the patient should be removed into a 
new room where every association with his sickness will be re- 
moved. He is to be shaved and freshly dressed. His diet should 
consist at first of the farinaceous articles. Next may be allowed, 
chicken-water, essence of beef, soft boiled eggs, oysters, boiled 
chicken, &c. To eat often, and but little at a time, is a golden 
rule in convalescence. 

Pure water is generally the best drink, though should the con- 
dition require it, malt liquor is better than wine or ardent spirits. 

Very slowly should the patient return to the usages of life. 
Especially should much intellectual or physical exertion be 
avoided. 

After complete apparent recovery, the pulse will sometimes 
retain a singular celerity. This, for the most part, subsiding 
spontaneously, may yet be the consequence of some cardiac 
lesion, perhaps of effusion, and require rest, low diet, and small 
doses of digitalis and colchicum. 

The patient, however, remaining feeble and without appetite, 
resort should be made to the tonics, — elixir vitriol, bark, the pure 
bitters, &c. 

Excessive vigilance is incident to convalescence from this fever. 
It may arise from cerebral excitement, original or reflected from 
some abdominal viscus, or from what is called nervousness. In 



70 DISEASES OF THE CIRCULATORY SYSTEM. 

the last case, it may be treated by the acetous tincture of opium, 
morphia, lupulin, henbane, Hoffman's anodyne liquor, or the 
spider's web. Arising from an empty stomach, it may be obvi- 
ated by a little food taken an hour before retiring. 

Diarrhoea is to be treated by laudanum ; costiveness by rhu- 
barb, which laxative is not incompatible with the opiates that 
may be required by other affections. 



YELLOW FEVER. 



This disease, although expressed by many different names, 
has never yet received a judicious one. It has been called 
typhus ictorodes, typhus cum floridine cutis, maladie de Siam, 
by the French, and vomito prieto, or chapeionado, by the 
Spaniards. The yellow fever is an endemic of tropical cli- 
mates, though occasionally incident to more temperate regions. 

SYMPTOMS. 

INTRODUCTOR Y«— Generally, lassitude, stiffness of limbs, 
and uneasiness in the back, loins, and calves of the legs. Soon 
after, a sense of coolness, which is succeeded after many hours, 
or more speedily, by a dry, hot skin ; dull, or acute pain of the 
head, darting through the eyeballs; injected eyes, and a coun- 
tenance expressive either of fierceness or incipient drunkenness. 
Sometimes, however, the countenance betrays no change, or 
even a preternatural serenity, or a look of great distress, with 
lachrymation, or a malignant frown, and the face is either 
leadened or bronzed, with a marble-like expression. The mind 
usually preserves a singular integrity throughout the disease, 
though there may be from the beginning indications of its aber- 
ration or weakening. Epigastrium tender, possessing often a 
burning sensation, with anxiety and oppression at the prsecordia. 
The boiceh usually maintain an obstinate torpor; the tongue 
is little changed, or white and fuzzy. 

AFTER THE FIRST TWELVE HOURS.— An exacerbation 
of the fever. Evidence of undue accumulations of blood in one 
or more of the viscera. Deep sighing, nausea, retchings of 



mucus, or glairy albuminous matter. Vomiting seems to take 
place by an irregular convulsive movement of the diaphragm. 
Wretchedness; the tongue milky, broad and fuzzy, or florid, or 
of a fiery redness, or perfectly natural. 

NOT ARRESTED, the case now rapidly becomes worse. 
The eyes assume a dirty yellow colour; circulation more irre- 
gular, the carotids, in particular, pulsating strongly ; the surface 
damp or sweaty, with a state of skin approaching to oedema, 
and of a yellow hue, though this last occurs only in cases of 
extraordinary malignity. Frequently, sore throat ; difficult de- 
glutition, and, sometimes, paralysis of the extremities. 

TOWARDS THE CLOSE OP THE THIRD DAY.— Notunfre- 
quently an apparent abatement of most of the bad symptoms. 
Soon afterwards, however, supervene almost unquenchable 
thirst, and discharges usually of the dark, flaky, granular 
matter, called black vomit. Contemporaneously occur a reduc- 
tion of temperature, and decrease of vascular action and mus- 
cular power, though the last may be fully retained to the end. 
Feeble pulse, cold colliquative sweats, involuntary diarrhoea of 
matter like the black vomit, haemorrhages of dark blood, low 
delirium, with coma ; laborious respiration, singultus, collapsed 
countenance, muddy eye, tumid abdomen, occasionally sallow 
or livid skin. 

Sometimes, however, there is an anomalous absence of many 
of the derangements which we have just described. The pa- 
tient is unconscious of disease, and, without manifest delirium, 
insists upon going out and resuming his avocations. But even 
here, the peculiar countenance, the deep sighing, and tender epi- 
gastrium, distinguish the disease. This serene state will in two 
or three days terminate by a sort of swooning away, or will 
become more developed by the supervention of black vomit and 
other characteristics. In other cases, death takes place without 
the slightest premonition, and with the suddenness of a blow. 

Sometimes is the disease shown only by pain in the toe, or 
some other anomalous part. Priapism has been also remarked 
as the only manifest affection, Also, in the female is apt to 



YELLOW FEVER. 73 

occur pruriency of the pudenda. The epidemic seems to select 
for the force of its attack, the part most predisposed. Displayed 
generally in the epigastric region most forcibly, it may fall on 
any of the lower viscera, or the lungs, or the cerebral, mus- 
cular, or nervous system, the affection of which may be so 
preponderant as to obscure the real disease. 

CAUSES. 

Dr. Chapman believes that the disease is of domestic origin. 
He thinks, however, that it may be generated from the materials 
which are contained in the holds of ships, and that it is never 
carried by fomites. But the distempered atmosphere of a 
port at which the fever is raging, may be confined in the hold 
of a vessel which is hermetically sealed, until the hatches are 
opened in another port. During this time the crew will not of 
course be subject to the disease, though they may acquire it at 
the opening of the hatches. Likewise when the miasm is 
generated from a putrefying cargo, the crew may be exempt 
until the hold is opened. 

It is equally certain, however, that the same kind of miasm 
may be evolved by the putrefaction of domestic filth in certain 
positions, as was evinced by the fever in this city in 1805, and 
in Baltimore and New York. Whether exhalations from filth, 
local or imported, will be productive of this fever under all cir- 
cumstances, remains to be determined. Reasons there are, 
however, to suspect that the tendency to spread is enhanced by 
high temperature steadily preserved. We may suppose, also, 
that the generation of the miasm is dependent on a certain 
constitution of atmosphere. 

The fact that the miasm of yellow fever is never generated 
beyond the watery margin of the city, was originally asserted 
by Dr. Chapman; and though the contrary has been affirmed, the 
proofs alleged have not been conclusive. Could mere masses 
of putrefaction produce the miasm, it would exist throughout 
the country, where these are most abundant. The filth of our 
cities proves inoperative to this effect, except in this particular 
situation. The fever has invariably appeared along the wharves, 



74 DISEASES OF THE CIRCULATORY SYSTEM. 

and rarely extended itself far into the city, or beyond the influ- 
ence of this position. In this city it was the opinion of the most 
experienced of our practitioners, that Third Street, which was 
little above a third of the city, constituted the limit of atmospheric 
distemperature. The same thing has been reported of the yellow 
fever, as it appears in South America and in the West Indies. 
The only exception is in Spain, where it is represented occasion- 
ally to have prevailed in some of the interior cities. But whether 
such really be the fact, or the disease be the ordinary typhus of 
Europe, our information at present is too indefinite to enable us 
to determine positively. As to our own country, similar state- 
ments have been made. They are, however, illy authenticated. 
The fever is said to have occurred repeatedly at Natchez ; but 
this fever has a much closer affinity to our ordinary bilious, 
than to the yellow fever. Yet, in consistency with Dr. Chap- 
man's principle, which claims the influence of water to be an 
element necessary in the production of the yellow fever, it is 
possible to suppose that the fever is occasionally generated along 
our great lakes and rivers. That the fever should be generated 
only in this watery position, may be attributed to the moistness 
of the filth, though this is only conjectural. The materials from 
which the exhalation proceeds, are in some cases doubtless 
very small ; yet reflecting on the wide-spread diffusion of the 
odour thrown out by musk, it may be readily conceived that 
the effluvium, arising from a source hardly visible, might still 
be highly operative. 

Fevers do arise in situations where none of the materials of 
miasmata exist. The yellow fever here, as in other places, 
avoiding, as it were, foul and dirty wharves, has broken out on 
the neatest. But this may be perhaps explained on the suppo- 
sition that where the surface is dry and clean, there are accu- 
mulations below, from which, through the crevices, the poisonous 
miasm escapes. It may be m^gea^**' affirmed, that the fever 
has generally appeared and raged to the greatest extent on 
wharves recently made, aM filled up with the filth of the streets 
and argillaceous soil of cellars. 

Yet, contrary to all this, has it been affirmed that yellow fever 
is of contagious origin. By contagion, it is presumed, is here 



YELLOW FEVER. 75 

meant what the word legitimately signifies, — a virus generated 
in one individual, through vitiated vascular action, capable of 
communicating the disease to a second, and so of multiplying it 
indefinitely. Opposed, however, to the doctrine of contagion, 
are the following considerations : — 

1. The fever is sometimes an epidemic, in its nature, laws, 
and effects. 

2. The disease has in no well-attested instance spread, when 
removed from the infected districts. In our hospitals, was this 
fact most conclusively exhibited. Here, the nurses, physicians, 
and other attendants, though exposed as much as possible to 
any contagion which might have existed, were exempt from 
the disease. As an experimenlum cruris, the black vomit, the 
saliva, and the serum of the blood, have been harmlessly 
inoculated into the system. The vapour, also, from the black 
vomit has been breathed, and two ounces of it have been swal- 
lowed, with impunity. 

3. The disease has been invariably suppressed on the acces- 
sion of cold weather, differing in this respect from contagious 
diseases. These, from the free ventilation, or from the volatility 
and diffusion of the virus, are less prevalent in warm weather. 

4. In contagion, the sphere of communication is very narrow. 
But in numberless instances has yellow fever been taken by in- 
dividuals, who had held not the slightest intercourse or proximity 
with the sick, but who had merely passed through the street in 
which the contagion was alleged to reside. 

5. Even the line of demarcation may be drawn with tolerable 
precision, indicating the limits of danger, excepting when the 
poisoned air may be wafted over it by the force of winds. Dr. 
Chapman has always found the spread of the fever to be in the 
direction of the wind. 

6. Unlike contagious diseases, which originating in a single 
point, thence radiate, yellow fever simultaneously appears in 
remotely separated positions. 

7. In favour of the non-contagious character of the disease, 
an appeal might confidently be made to probably nine-tenths of 
the profession who have had opportunities of becoming con- 
versant with it. This argument has some force, from the fact 



76 DISEASES OF THE CIRCULATORY SYSTEM. 

that the question is one so much dependent for its solution upon 
the mere observation of simple phenomena. 

But it has been alleged, that while the fever is not generally 
contagious, it does under certain circumstances prove so, — 
as in crowded, ill-ventilated places. But this assertion, how- 
ever plausible, is wanting in proof. The cases alleged in 
support, are only five or six in number, which occurred in the 
country, where the yellow fever seldom or never exists, and in 
the practice of men who, from want of acquaintance with 
yellow fever, would be unable to distinguish it from malignant 
cases of ordinary autumnal fever. It is indeed to be recollected, 
that according to the erroneous doctrine of the time, the only 
difference in the two diseases, regarded their degree of violence. 

In the immunity which is rendered by one attack of yellow 
fever, this disease has been said to resemble contagious diseases. 
But it is untrue, that in contagious diseases subsequent protection 
is so generally afforded by one attack. No agreement exists 
among the advocates of the hypothesis, as to the mode in which 
this disease, acknowledged in its general character to be other- 
wise, becomes contagious; or, in other words, how a vitiated 
atmosphere operates in the case. Chisholm says, that it merely 
increases susceptibility to the impression of the virus already 
received into the system, and at the same time enhances the 
action, giving the fever a more aggravated and malignant 
shape. 

Professor Hosack maintained some " chemical combination 
with the virus already secreted from the diseased body, and 
that thereby the contagion becomes more or less multiplied 
according to the extent and virulence of such vitiated atmo- 
sphere." Disclaiming, as he does, the notion of a tertium quid 
being formed in the operation, such would nevertheless evidently 
result. — 

Professor Rush supposed the contagion to originate in an exha- 
lation from the excretions of the patient : but were such the case, 
the disease thus produced would be as diversified in its nature 
as the effluvia from these various sources. Contaminated air, 
however, Dr. Chapman does believe to influence yellow fever, 
by the induction of a typhoid state. The typhoid impression 



YELLOW FEVER. 77 

may even be so strong as to supplant the primary nature of the 
disease, but then the contagion would be of typhus, and not of 
yellow fever. 

By the researches of Webster, it has been demonstrated that 
all climates are liable to the periodical visitation of epidemics, and 
that they alternate as regards their general character, two of the 
same nature never occurring in immediate succession. In our 
own country the yellow fever was repeatedly alternated with 
the spotted fever, a species of typhus. 

It is to be lamented, however, that in all countries in which 
legislation has attempted to put barriers to the progress of yellow 
fever, the most harassing laws are founded upon the almost 
exploded doctrine of contagion. 

EXCITING CAUSES. — The ordinary exciting causes of 
febrile affections. Sleep seems to have some tendency to its 
production. In this state, the greatest proportion of attacks 
takes place. 

Period of Incubation. — The average period is from two to 
three days in the commencement of the epidemic, becoming 
greater towards its close, as the poison is, probably, more 
diluted. 

DIAGNOSIS. 

Distinct from its exclusive prevalence in cities, and along the 
wharves, there are peculiarities in itself, so striking, and par- 
ticularly the countenance of the sick, that it has scarcely ever 
been mistaken. It bears the closest resemblance, perhaps, to 
aggravated autumnal fevers. They differ in the following re- 
spects : — 

1. Yellow fever originates in a miasm, which is generated 
only in particular positions, and at certain times; while, to a 
greater or less extent, common bilious fever is incident to many 
climates and all seasons. 

2. The diseases differ in type and in symptoms. The diffe- 
rence is manifested in the pulse, tongue, respiration, discharges 
from the stomach, condition of the secreting power of the liver, 



78 DISEASES OF THE CIRCULATORY SYSTEM. 

in the muscular and nervous systems, in the countenance, and 
especially in the expression of the eye. 

3. The yellow fever has its seat and throne in the stomach, 
while the bilious, though of gastric origin, chiefly involves the 
liver. 

4. The convalescence from yellow fever, is rapid and com- 
plete ; from bilious fever, slow and precarious. In yellow fever 
the susceptibility to the disease is destroyed or diminished by an 
attack ; in bilious fever it is increased. 

5. The treatment adapted to bilious fever, totally fails in yel- 
low fever. 

6. The mildest case of yellow fever is as easily designated as 
the most violent and malignant. 

PROGNOSIS. 

Like other malignant epidemics, the fatality is greatest at its 
first appearance, and afterwards gradually declines. 

Cases marked by forcible reaction and high fever, are most 
favourable ; and the reverse are those connected with confirmed 
relapse, extreme epigastric, or precordial uneasiness, jactitation, 
delirium, or coma, or vomitings of tenacious albuminous matter. 
Still more desperate are the cases, which, with the peculiar 
physiognomy, little or no affection is evinced. Especially 
ominous is an eager desire for food, and, above all, solid animal 
food, with the morbid venereal feelings, to which allusion has 
been made. Of the worst import is that exquisite nervous sen- 
sibility productive of tetanus or hydrophobia, or where the whole 
suffering, to an excruciating degree, is concentrated in a part 
(the pudenda, or testicles, more commonly), or the tongue in 
an advanced stage, suddenly clearing, or the pulse, previously 
bad, becoming, with a deterioration in other respects, conspi- 
cuously better, or the occurrence of the black vomit. Cases thus 
characterized do not recover. 

The disease mostly terminating on the third or fifth day, may 
do so in a few hours. 

However severe the case, convalescence is almost incon- 
ceivably rapid and complete. 



YELLOW FEVER. 79 



AUTOPSIC APPEARANCES. 

The most prominent lesions are in the epigastric region. On 
opening the stomach we discover, sometimes a dark fluid, here- 
after to be described, and the food, drinks, and medicines taken, 
in some instances, several days before, wholly unaltered by the 
digestive process. The mucous membrane presents the evi- 
dences of phlogosis. These are also manifested by the duo- 
denum. Nearly always, in Philadelphia, has the liver been 
healthy, though the reverse has occurred elsewhere. Impli- 
cated also, occasionally, are the spleen, kidneys, urinary 
bladder, heart, and lungs. The brain is but little affected, even 
when cerebral disorder is strongly marked. 

During the last years of its prevalence, instead of the in- 
flammatory, the fever presented the congestive character. 

In the year 1820, when the Philadelphia Yellow Fever Hospital 
was under the charge of Drs. Chapman and Hewson, two im- 
portant facts were there established. The black vomit was 
determined to be only blood more or less altered: in proof of 
which, it might be visibly pressed out of the vessels. It was 
observed also, that whenever this fluid had been discharged in 
great quantities, the mucous coat presented a pallid hue. The 
general appearance of the fluid is that of coffee-grounds, or the 
sediment of port wine, though it is sometimes sero-sanguineous, 
and sometimes exactly like the menstrual fluid. The black 
vomit, when fresh, was found to be replete with animalculas. 
The blood was exhibited from the concrete mass, to absolute 
fluidity. Dr. Chapman never saw it fully separated into its 
constituents, crassamentum and serum. 

Cases have been reported as being destitute of all lesion. 

The black vomit is not pathognomonic of yellow fever. 

PATHOLOGY. 

The nature of this fever is still almost as much disputed as 
other points in its history. Like other epidemics, influenced 
by various agencies, it is sometimes inflammatory, and some- 



80 DISEASES OF THE CIRCULATORY SYSTEM. 

times congestive. Sometimes the two conditions are blended. 
The disease originates in a peculiar irritation, or congestion, 
or inflammation of the stomach ; which is proved as well by 
the symptoms, as by dissection. This state involves the nervous 
connexions of that organ. 

Between yellow fever and the condition induced by certain 
poisons, both in commencement and progress, has often been 
observed the most striking parallel. This parallelism is most 
remarkable, and may be traced by any one acquainted with the 
action of poisons. Dr. Chapman, then, considers the disease 
to consist in the action of an extremely virulent poison upon 
the stomach, producing excessive disorder of that viscus, and 
involving other parts sympathetically. 

TREATMENT. 

Dr. Chapman enters upon this subject with the confession 
that he is aware of no kind of practice deserving of much con- 
fidence. Mistaken in the year 1793 for a species of typhus, it 
was treated, after moderate evacuations, by wine and bark. 

Mistaken afterwards for a form of the ordinary autumnal 
fever, it was treated by copious venesection, and subsequently 
by brisk purgations, and sometimes by emetics. 

While the last course was pursued, some French practitioners 
from St. Domingo, instituted a new practice. Their remedies 
were adapted to calm the irritation of the stomach. Having 
checked vomiting by the ordinary means, their next object was 
by diluent beverages to wash out the offending cause. 

Of these kinds of practice, the last, if not the best, was at 
least the most harmless. 

Encouraged by reports from the West Indies, an essay was 
early made of the mercurial plan. But on the whole, it appeared 
that in violent cases the mercurial impression could not be pro- 
duced, and that in milder forms it was unnecessary. Nor is a 
salivation uniformly successful. The practice has lost ground 
in the West Indies. 

A more correct pathology having been developed by post 
mortem dissection, remedies were employed suited to the reduc- 



YELLOW FEVER. Q\ 

tion of a gastritis. These remedies consisted in the lancet, 
leeches, fomentations and blisters, to the epigastrium, with 
active purging by calomel, alone, or variously combined. Vas- 
cular action being high, cold was applied to the surface, and 
subsequently sweating was induced by the lenient diaphoretics 
and the vapour bath. Vomiting was restrained by ten or 
twelve drops of turpentine frequently repeated. In a sinking 
condition, the system was upheld by the proper stimulants. 
This practice was in the end very generally adopted. 

Jn New York was adopted the practice of the French 
physicians, combined with the more liberal employment of the 
diaphoretic measures. 

With these plans of treatment the mortality was dreadful. 
In Philadelphia more than half the cases ended fatally; seven- 
tenths died at Cadiz ; and four-fifths at Gibraltar. 

Convinced of the inefficacy of all the existing modes of treat- 
ment, Drs. Chapman and Hewson, during the last epidemic in 
this city, instituted a new practice, founded upon the analogy 
between this disease and poisoning from acrid substances. 

Emetics. — These were limited to the earliest stage, when 
the stomach was yet uninflamed. Their object was to remove 
the offending cause, or to break up the primary morbid impres- 
sion on the stomach. 

Lenient Purging, with calomel, or castor oil, &c. 

Next followed an exhibition of the 

Oil of Turpentine, in doses commonly of a drachm, every 
hour or two. This was taken alone, or combined with the car- 
bonate of ammonia, or some essential oil, which latter rendered 
it more retainable by the stomach. Further evacuations from 
the bowels being demanded, a drachm of turpentine was com- 
bined with an ounce of castor oil. 

Unless it be applied very early, the turpentine, in common 
with all other remedies, will be for the most part unavailing. 
The vitality of the stomach, after ten or twelve hours, is nearly 
destroyed, and remedies then applied to it are inert. Applica- 
tions to the skin will be found equally ineffectual. 

Although many patients were brought into the hospital late in 
the disease, yet out of sixteen thus managed, twelve recovered. 

6 



82 DISEASES OF THE CIRCULATORY SYSTEM. 

The principle on which the turpentine was employed in the 
early stage of the disease may be vindicated. — 

Of the counter-agency of turpentine in scalds and burns, we 
are aware. The stomach in yellow fever is in a state probably 
similar. We know also that in many instances the turpentine 
is soothing in its effects on the stomach, removing the sense of 
heat and irritation in that viscus, and subduing the force of vas- 
cular action and general excitement. The turpentine, much 
about the same time, was prescribed in the plague of Malta, 
and it is strenuously recommended as the best corrective of the 
gastritis from acrid poisons. Dr. Chapman has for a number 
of years used turpentine in peritonitis, already partly subdued 
by depletion. In dysentery, at that point when gangrene is 
menaced, turpentine is more useful than any thing else. It is 
excellent also in cholera infantum, in a somewhat earlier stage; 
and in chronic diarrhoea, in which the mucous coat of the in- 
testines is chiefly affected, it is an incomparable remedy. 

But suppose, what is perhaps most frequent, that a state of 
feeble congestion should prevail. All are agreed to the superior 
efficacy of the medicine in other low fevers so circumstanced, 
and not less so in haematemesis of like character. 

With similar views, and somewhat successfully, was pre- 
scribed the acetate of lead. 

Yet, in conclusion, it must be acknowledged, that the turpen- 
tine will not always answer, and sometimes aggravates the 
disease. 

The fever was treated by Dr. Stephens by certain neutral 
salts, to replenish the blood with its saline ingredients. Dr. 
Chapman's unfavourable remarks on this treatment are con- 
tained in his lectures on typhus. 

Again, in the extreme southern portion of our country, has 
the disease been met in its inchoative stage, by immense doses 
of quinine. This plan Dr. Chapman has never seen tried ; yet 
he cannot help regarding it as a pernicious extravagancy. 

Dr. Chapman professes to have no great confidence in any 
scheme of treatment hitherto proposed. 

.PREVENTIVE RE GUL ATIO H S.— The quarantine laws 



YELLOW FEVER. 83 

should be restricted exclusively to foul vessels. The cargoes 
of all suspicious vessels should be discharged at a distance 
from the city, nor should an entrance be allowed, until all such 
vessels he thoroughly purified. 

In the construction of wharves, Dr. Chapman proposes to 
substitute stone for wood, and to fill up the interior w T ith stone, 
instead of earth or the rubbish of the city. 

Should the locality, from which the miasm proceeds, be 
densely built, a freer ventilation should be afforded by the open- 
ing of new streets. 

The ordinary filth of the city should be removed ; for though 
it cannot originate, it may aggravate the disease. 

When the disease breaks out, the infected spot and its imme- 
diate vicinity should be evacuated, and all intercourse with 
them carefully avoided. It is, however, better to avoid dis- 
turbing the sick. 

The stomach should be supplied frequently with food, which 
acts either by shielding the susceptible surface of that organ, 
or by calling into action the digestive process, by which the 
poison is destroyed or neutralized. The diet, clothing, state of 
mind, &c, should be properly regulated. 

Thinking it probable that the miasm ascends to no great 
height, Dr. Chapman advises persons who are obliged to remain 
in the infected district, to retire at sunset to the upper part of 
the house. 

The efficacy of fumigations of chlorine, or of sprinkling the 
distempered district with the carbonate of lime, is to be decided 
by future experience. 



PNEUMONIA TYPHODES. 



Synonymes, spotted fever, cold plague, &c. 

First attracting notice in New Hampshire and Massachusetts, 
in 1806, it afterwards swept gradually through the whole 
United States. It appeared for the first time in Philadelphia in 
1813, but reappeared the next winter in more fearful strength. 

SYMPTOMS. 

The disease was Protean ; but generally the patient was sud- 
denly and unexpectedly attacked with great prostration. An 
alternation of chills and heats; skin becoming dry, pale, and 
mottled, face bronzed, physiognomy exceedingly anxious ; de- 
lirium, followed by stupor. In some instances so rapid was 
the onset, that persons were cloven down as by a stroke of 
lightning. On other occasions, the disorder was ushered in by 
all the circumstances of pneumonic inflammation, or congestion. 
In the south, there was uniformly some gastric distress. 

So far, in many cases, the affection may have been mistaken 
for bilious pleurisy ; but the extreme atony, together with 
pneumonic disease and mental disorder which certainly suc- 
ceeded, dissipated all doubt. The tongue became a dark brown, 
like that of the black tongue fever of the west. 

In Virginia, the throat was generally the most prominent 
point of invasion. 

CAUSES. 

Its origin is involved in doubt. From its prevalence in the 
winter, and disappearance on the approach of warm weather, 



PNEUMONIA TYPHODES. 85 

it would seem to be in some way dependent on cold. To this 
supposition, also, the similarity of fevers which are certainly 
thus produced, lends support. 

But from the universality of its prevalence, as well as its obe- 
dience to the laws of epidemics, we must refer it to a distem- 
perature of the atmosphere — vague as this explanation is. Like 
other epidemics, it gave a complexion to all other diseases. So 
much was this the case, that throughout the country the lancet 
was generally abandoned — a revolution in practice, from whose 
effects we have not yet wholly recovered. 

The exciting causes are not peculiar. 

The disease has occurred at various times, both in this 
country and Europe ; and in a mitigated form, it occurs among 
the poor every winter. 

PROGNOSIS. 

When the countenance would assume a placid, inanimate ex- 
pression, with the skin polished, and of a leaden or bronzed 
complexion, hope was diminished. But the most alarming cases 
were those in which the patient seemed to be little affected by 
his disease, could not be persuaded of his danger, and would 
persist in being up. These much resembled the walking cases, 
in yellow fever. But on the whole, the epidemic was more 
manageable than the last-named disease. 

Its duration varied from a few hours to several days. It 
commonly terminated, however, on the third or fifth day. Con- 
valescence was rapid and complete. 

AUTOPSY. 

Engorgement, usually of the brain, lungs, heart, and spleen. 
The throat tumefied and purplish, spotted with fragments of 
lymph, or covered with a pellicular coating of it. Livid 
patches, limited to the upper portion of the alimentary canal, 
or extending to the bowels. The blood was like that in other 
malignant fevers. 



8(5 DISEASES OF THE CIRCULATORY SYSTEM. 



PATHOLOGY. 

A state of congestion, produced in a way already fully de- 
tailed under other heads. 



TREATMENT. 

As soon as the alimentary canal had been evacuated, it was 
found best, in this city, to make an active employment of 

Diaphoretics. In urgent cases, they anticipated purgatives. 
The best were those into which 

Opium entered, particularly when there was pain. Dr. 
Chapman preferred the 

Dover's Powder; with which were combined the free use 
of strong 

Wine Whey, the Vapour Bath, and Hot Fomenta- 
tions, to the lower extremities, the trunk, and armpits. 

As the disease advanced, with diaphoretics were united the 

Cordial Stimulants, of which the best was the carbonate 
of ammonia. Here, too, the 

Oil of Turpentine may be of use. The vital powers still 
sinking, 

Stimulating Frictions became necessary. 

There being, however, determinations to the throat, chest, or 
liver, 

Emetics of salt and mustard were preliminary measures. 
Then a mercurial purgative was directed. Local congestions 
were afterwards managed by 

Local Bleeding and Blisters. 

Venesection would not answer in this city. 



DISEASES OF THE HEART AND 
BLOOD-VESSELS. 

These, until the commencement of the present century, re- 
ceived but little investigation. 

Dr. Chapman arranges them as follows: 
INFLAMMATORY. 

Acute and Chronic. 
ORGANIC. 
NERVOUS, 

Real and Sympathetic 
The diagnosis of inflammation of the heart or its tissues, from 
that of the lungs, is confessedly difficult. 

In the former, however, we have the pain more severe, and 
seated in the region of the heart; greater deviations in the cir- 
culation, and the respiration and the sputa are less affected. 

Disorganization of the heart may be suspected from the fol- 
lowing 

SYMPTOMS. 

Bloated face ; tumid lips ; the complexion and lips purplish, 
though sometimes florid, or of a waxy pallor, with edematous 
swellings, particularly about the eyelids ; countenance thin and 
sharp, eyes prominent and staring, and the face haggard ; respi- 
ration short and difficult, with the difficulty greatly increased 
on exertion or mental emotion; in bad cases, an inability to 
maintain the recumbent posture, and sleep disturbed by fright- 
ful dreams ; frequently dyspepsia, and, as a consequence, per- 
haps, of the gastric irritation, petulance and melancholy. 



88 DISEASES OF THE CIRCULATORY SYSTEM. 

But more is to be learned from the circulation. Heart's action 
commonly, though not always, irregular, as is betrayed by pal- 
pitations and great variations in the force of the pulse. Engorge- 
ment of the superficial veins, a tumultuous circulation, or a pul- 
sation in the larger veins, especially the jugular. Hence occur 
venous congestions, haemorrhages, and dropsies, 

PRIMARY IRRITATION of the heart may be either spas- 
modic or neuralgic. The former is denoted by the peculiar 
nature of its pain, sudden remission, and the extraordinary irre- 
gularity of the heart's action. The neuralgic affection is denoted 
by a pain singularly sharp and darting, with less disturbance of 
the heart and pulse. 

SYMPATHETIC IRRITATIO N,— Great disorder of circu- 
lation, and almost invariably dyspepsia. 

As CONSEQUENT upon cardiac disease, are the various 
forms of cerebral disorder — particularly apoplexy — besides, in- 
flammation or congestion of the pleurae, lungs, liver, kidneys, 
uterus ; thickening, or other changes in the alimentary canal, 
and haemorrhoids. 

CAUSES. 

As is predicable from the peculiar exposure of the heart to 
corporeal and moral influences, diseases of this organ are quite 
numerous. 

Hereditary disposition, connected or not connected with 
malconformation. There is a greater inclination in the male 
than in the female. Cold, damp, austere weather, seems to 
act as the most prolific cause. Rheumatism and gout, mis" 
placed, or metastatic. Excessive labour in doors, and in dis- 
torted positions of body. The consumption of ardent spirits. 
A stimulating, or, what Dr. Chapman believes was first indi- 
cated by himself, a penurious diet. Inordinate venerial indul- 
gence, or masturbation. Recession of cutaneous eruptions — of 



DISEASES OF THE HEART AND BLOOD-VESSELS. gQ 

the exanthematous, and still more, of the chronic. The strumous 
diathesis, and the syphilitic taint, are alleged causes. 

Affections of other organs, such as various pulmonary dis- 
eases, chronic irritations of the prima? vias, enlargement of any 
of the abdominal viscera, pregnancy. 

Moral Emotions. — Cardiac diseases wonderfully increase dur- 
ing times of public terror. So violent is the action of the heart 
when sympathetic of the emotions, that it sometimes literally 
bursts. 

Besides this, the heart may be affected by whatever acts 
noxiously on the system. Hence it is, that the pulse is so often 
appealed to, as affording the most faithful criterion of morbid 
conditions. 

DIAGNOSIS. 

Very obscure. 

By Physical Sig?is. From percussion little aid will be de- 
rived. This deficiency is in part obviated by auscultation; 
though Dr. Chapman concurs with Andral, when he says that 
auscultation may indicate lesions of the heart, where none ex- 
ists ; and, conversely, furnish no signs of such, when actually 
prevailing to a considerable extent. And again, after stating 
that it often gives very useful and necessary information, An- 
dral adds, — though alone, and without the aid of other signs, it 
cannot, except in some rare instances, show certainly the exis- 
tence of these affections. 

To acquire the arts of percussion and auscultation, requires 
an ear and training, which few practitioners can command. 
There are many false pretenders to proficiency. 

Instruction in this branch is resigned by Dr. Chapman to the 
anatomist and the clinical teacher. 

PROGNOSIS. 

From the importance of the heart, and the inferior opportu- 
nity afforded for recovery by its ceaseless motion, cardiac 
diseases are invested with extraordinarv danger. Yet some 



90 DISEASES OF THE CIRCULATORY SYSTEM. 

cases may be cured, and others so palliated, that life may be 
prolonged with considerable comfort. 

AUTOPSIC APPEARANCES. 

The appearances of the heart are detailed in the consideration 
of its specific diseases. But whatever the affection may be, 
provided it has been long continued and severe, a sensible in- 
crease takes place in the size, and weight, and of the viscera of 
the three great cavities. 

PATHOLOGY. 

Dr. Chapman reserves what concerns the pathology of the 
special lesions. 

Though organic changes are chiefly referable to inflammatory 
action, yet some of them occur independently of it, or, at least, 
without its ordinary manifestations. 

Of organic affections there are three varieties : hypertrophy, 
caused by an excessive supply of blood ; atrophy, caused by an 
inadequate supply ; and alterations of structure, or new forma- 
tions, caused by a vitiation of the nutritive functions. 

TREATMENT 

Should be most prompt. Of the first importance is it, to dis- 
tinguish the inflammatory from the purely nervous. The reme- 
dies in the former, are depletory and evacuant, and subsequently, 
sedative; in the latter, or nervous, they are, in most respects, 
the reverse. 



CARDITIS, PERICARDITIS, AND 
ENDOCARDITIS. 



Inflammation of the muscular substance of the heart itself, 
has been said to be extremely rare. This Dr. Chapman doubts; 
and he refers the absence of inflammatory appearances in post 
mortem examinations, to the well-known indisposition of the 
muscular tissue to disclose the usual demonstration of phlogosis. 
Still, it is much less common than pericarditis. But believing 
that the heart and its membranes may be simultaneously in- 
flamed, and that when any one is exclusively so, we have no 
means of ascertaining the fact with certainty ; and above all, 
that could it be done, the treatment would be the same, Dr. 
Chapman prefers embracing the three phlegmasia? under one 
head. 

SYMPTOMS. 

Vary much, according to the violence of the attack. 

INCIPIENT. — Commonly like those of pleuritis, or pneu- 
monitis. 

MORE ADVANCE D. — An acute lancinating pain, sense of 
heat and constriction in the precordial region, extending to the 
scapula or shoulder, and arm, down to the elbow, increased by 
pressure between the ribs, and by a deep inspiration. Some- 
times, however, pain is absent ; or it is trivial, or dull, and 
fixed ; and may be fell, in all its states, most in the epigastrium, 
or left hypochondrium. 

Inability to change the position, particularly to the left side, 
or to straighten, or lie on it; restlessness, anxiety, anguish; 



92 DISEASES OF THE CIRCULATORY SYSTEM. 

face pale, or occasionally flushed in the left cheek, or tumid, 
and sometimes leaden, at times bedewed with perspiration ; a 
disposition to syncope. 

Very characteristic is the inability to assume the recumbent 
posture, relief being afforded by the trunk being bent, and the 
arms resting on some support in front. Heart usually bound- 
ing and forcible ; pulse strong, full, and tense ; though the former 
may be feeble and irregular, and the latter small, corded, inter- 
mittent, and jerking, or thrilling. The pulses of the two arms 
may vary. Urine high-coloured and scanty; bowels consti- 
pated, or healthy. 

Headache, distraction of the senses, jactitation, delirium, dis- 
tortion of countenance, which may assume the expression of 
terror or despair. 

Complications, with inflammation of the lungs, or their con- 
nexions, or with other affections. 

Cases resulting from sudden metastasis of articular gout, or 
rheumatism, are marked by sharp, spasmodic pain, and labo- 
rious action of the heart, with great irregularity of circulation, 
and pulsation in the veins of the neck. 

CAUSES. 

Already detailed in the general discussion of cardiac diseases. 
In this city, this disease prevails most in winter, and among 
those under the age of puberty. 

DIAGNOSIS. 

This, Corvisant thinks difficult, from the frequent complica- 
tion of other phlegmasia? of the chest. But in its simple form, 
Dr. Chapman has easily recognised the disease. The peculiar 
countenance is very distinctive. 

Endocarditis and phlogosis of the lining membrane of the 
pericardium are marked, like inflammation in other serous tis- 
sues, with acute, lancinating pain ; but occurring in the fibrous 
portion of the pericardium, or the heart itself, the pain is more 
like spasm, or it is rheumatic, or neuralgic. 



ACUTE CARDITIS. 93 

But endocarditis is said to be attended with little pain — with 
only a feeling of precordial oppression. At the same time that 
the heart's action is tumultuously violent, the pulse is feeble and 
intermittent ; and thence rapidly follow extreme debility, great 
dyspnoea, tendency to syncope, &c. Dr. Chapman, however, 
believes the simple and early character of the disease to be 
highly phlogistic, and the state just described to result from the 
mechanical obstruction of the valves, which may, from various 
causes supervene; or sometimes, perhaps, from the mixture of 
secreted pus with the blood. 

By Physical Signs. 1. PERICARDITI S.— When the effusion 
has become considerable, dulness of percussion. The contrac- 
tions of the ventricles, give a stronger impulse, and a sound 
more marked than in a natural state. At intervals of various 
duration, more feeble and shorter pulsations, corresponding to 
intermissions of the pulse. Exceedingly characteristic of peri- 
carditis, is commonly held to be the bruit de frottement — a sort 
of rubbing, or rustling up and down, compared to the friction 
of silk or parchment. This, at first heard faintly, near the 
centre of the sternum, gradually becomes more wide-spread 
and louder, and is then imitative of the creaking of the sole of 
a new shoe. From the last circumstance it is called the cri de 
cuir, or leather creak. It is produced by the opposing surfaces 
of extravasated lymph. But the value of this sign is much 
diminished by its frequent absence, its being inaudible, or by its 
being confounded with what closely resembles it, the sound 
emitted in valvular disease. The indications of serous effusions, 
are deferred by Dr. Chapman to the consideration of dropsy of 
the pericardium. 

2. ENDOCARDITIS.— Dulness of sound on percussion over 
the precordial region, or still greater space. Uniformly pre- 
sent is the bellows sound. 

What applies to valvular degenerations, is postponed. 



94 DISEASES OF THE CIRCULATORY SYSTEM. 



PROGNOSIS. 

All cardiac inflammations are alarming; of which, however, 
endocarditis is more so than pericarditis. Life may terminate 
very suddenly and unexpectedly. 

Commonly, such diseases, after running a course of several 
days, provided the brain and lungs escape, submit to our reme- 
dies entirely, or degenerate into some of those chronic states, 
hereafter to be noticed. 

AUTOPSIC APPEARANCES. 

The pericardium exhibits redness — arborescent, punctated, 
in patches, or diffused. A concrete exudation on its surface, 
like that in pleurisy, though thicker, more consistent, and rougher. 
Effusions of serum in the sac, amounting often to a pint. Some- 
times, though rarely, effusions of pus. 

In endocarditis, the lining membrane exhibits various colours, 
from a light rose tint to a bright red, or a purple or brownish 
hue, local or diffused. The inflammation is highest about the 
valves; and the tumidity there is such as must have interrupted 
the circulation. Discoloration alone is not decisive of inflam- 
mation ; there must be coincident vascularity, or tumefaction, 
or change of structure, or effusions of lymph, or pus. Co- 
agula of blood are sometimes met with, which, when organized, 
are called polypi. 

The heart itself is generally somewhat tumid, vascular, and 
changed in colour. Its surface is often coated with lymph, or 
spread with a collection of purulent matter. The interior of the 
heart is seldom much affected. 

Pulmonary lesions are, according to Louis, discoverable in 
two-thirds of the cases. 

TREATMENT 

Is simple, but should be highly prompt. 

Tene section,— Except in the aged, the inebriate, or other- 



ACUTE CARDITIS. 95 

wise infirm, or in the advanced stage, this measure should be 
freely employed, until evidence of relief is afforded. It is a 
remedy of primary importance. 

Topical Bleed in g. — To be repeated until the force of the 
attack is overcome, when we may resort to 

A Blister. 

A Purgative in the beginning, and subsequently, 

laxatives. 

Tartar Emetic, and Nitre.— Dr. Chapman is opposed to 
the use of immense doses of these articles. 

D i g i t a 1 i s. — On the whole, more to be depended on, than the 
articles just mentioned. 

C a 1 m e 1. — Used by Dr. Chapman in combination with opium 
and ipecacuanha. It is detrimental in leucophlegmatic or 
depraved constitutions, but is well adapted to the sanguineous 
or inflammatory, in which we suspect a disposition to the secre- 
tion of fibrine. 

Dover's Powder. — Useful in quieting spasmodic action of 
the heart. Dr. Chapman believes that diaphoresis has been too 
much neglected in carditis. He has found the Dover's pow T der 
particularly useful in arthritic and rheumatic cases. 

Cole hi cum seems, in the states just alluded to, to exercise 
a sort of specific influence. 

Stimulating Revulsives to the extremities, in order to 
invite a return of the rheumatic affection. 



CHRONIC CARDITIS, PERICARDITIS, 
AND ENDOCARDITIS. 

SYMPTOMS. 

Cases sometimes progress to a considerable extent, without 
attracting any notice. Generally, however, there is some febrile 
movement, from the first, or at least a hectic pulse. A jarring 
sensation given to the hand, when placed over the heart ; though 
there is seldom palpitation. 

Little or no pain in the precordial region, and when it does 
occur, it is obtuse and fugitive. But a sharp and permanent 
pain is sometimes felt in the epigastrium, hypogastrium, or 
between the shoulders. The stomach is sometimes irritable, and 
the head aching and giddy. 

Continuing for months or years, the case grows worse, and 
henceforward displays no material distinction from the second- 
ary form of the disease. 

The above is a portraiture of the ordinary form ; but arthri- 
tic and rheumatic cases vary considerably. In these is pain 
more acute and gnawing ; greater anxiety and oppression in the 
prascordia ; most violent palpitations, with a more disturbed 
pulse ; excessive dyspnoea upon physical or mental excitement, 
or the recumbent posture ; the disease at first distinctly parox- 
ysmal, and, when rheumatic, dependent on the states of weather; 
peculiar petulance. 

CAUSES. 

Like those of the acute variety ; or the disease may be a de- 
generation of an acute attack. It is oftener attributable to 
rheumatism than is the acute form. 



CHRONIC CARDITIS. 97 



DIAGNOSIS. 

Still more obscure than in acute carditis. Dr. Chapman, 
however, believes that in a large proportion of cases, a careful 
investigation will lead to a correct inference. 

PROGNOSIS. 

Of very difficult cure, yet not so intractable as to discourage 
our efforts. 

AUTOPSIC APPEARANCES. 

1. A firm adhesion is sometimes found between the 'pericar- 
dium and heart. The former is usually thicker and more 
opaque than is natural. 

2. The endocardium is thicker, more condensed, opaque, and 
rough, owing either to real hypertrophy, or to an adventitious 
membrane. This condition exists in an exaggerated degree 
about the valvular openings. The valves are rendered more 
or less adherent by lymph. But the valves, in addition, present 
divers structural alterations, which will be pointed out subse- 
quently. 

3. The heart itself betrays the evidence of inflammation, 
chiefly restricted to the superficial layer of muscular fibres. 
Abscesses and ulcers are occasionally found in the substance of 
the organ. But it is sometimes, after the long existence of effu- 
sion in the pericardial sac, discovered to be in an atrophied 
condition. 

P A T H L G Y,— Essentially the same with that of acute 
carditis. 

TREATMENT. 

When the case is recent, and we have an expectation of 
effecting a cure, we may resort to the following expedients : — 



98 DISEASES OF THE CIRCULATORY SYSTEM. 

Topical Bleeding, sometimes may be anticipated by vene- 
section. 

Counter-irritation. 

Tartar Emetic, Digitalis, or Cole hi cam. — According 
to the remarks made on their use, in the treatment of the acute 
disease. 

Calomel, Opium, andlpecacnanh a. — It is only by an 
alterative mercurial impression, that any very material anormal 
condition of the heart can be rectified. Dr. Chapman's trials of 
the iodine as a substitute, have not proved very favourable to 
that medicine. But he does not discourage a fairer trial. 

A Purgative at first ; subsequently laxatives, to keep the 
bowels soluble. The drastics are only of service for the re- 
moval of pericardial effusion. 

Regime n. — Simple food, in moderate quantities, with mental 
and bodily quietude, are highly important. 

This plan should be persevered in for a considerable length 
of time, according to Boerhaave's maxim, — that chronic dis- 
eases require a chronic treatment. 

Rheumatic cases are much benefited by a removal from 
an austere to a mild climate. 



ORGANIC CHANGES OF THE HEART. 



These, of late, have been multiplied with an inconceivable 
minuteness of division, which, however curious it may be, serves 
rather than otherwise to perplex, in practice. A common treat- 
ment belongs to a large portion, and the rest, with some excep- 
tions, are irremediable. 



HYPERTROPHY. 

This is an increase of the muscular parietes of the heart. 
With this augmentation of the walls, the cavity may retain its 
natural size, or it may be expanded, or contracted. The first 
variety is called simple hypertrophy ; the second, eccentric or 
dilated hypertrophy, or hypertrophy with dilatation ; the third, 
concentric or contracted hypertrophy, or hypertrophy with 
contraction. 

Hypertrophy may either embrace the entire organ, or it may 
be restricted to parts. 

SYMPTO M S. 

EARLY STAGE. — The most prominent symptom is the ex- 
traordinary force of the heart's action, in which the pulse usu- 
ally participates. The hand, applied to the precordial region, 
experiences a sort of rebound, the end of each shock being 
marked by what is called the back stroke, or diastolic impulse, 
ascribed to the refilling of the ventricles. The pulse, owing to 
the lengthened systole, is preternaturally protracted. The ca- 
pillary system has also an unusual activity, as is evinced by a 



100 DISEASES OF THE CIRCULATORY SYSTEM. 

florid, or even flushed face, and brilliancy of eye. Occasionally 
there is slight dyspnoea. 

ADVANCED STAG E,— Disorder of system, manifested by a pal- 
lid cachectic appearance; flaccidity of the integuments; dropsy, 
with oedema of the face ; embarrassed respiration, or still graver 
pulmonary affection. Most characteristic, however, is, perhaps, 
the disposition to hemorrhage. No organ or structure maintains 
an immunity from haemorrhage, though the fatal cases are most 
often presented in the form of cerebral, or pulmonary apoplexy. 
There is authority for believing that three-sevenths of each of these 
kinds of apoplexies are connected with this condition of heart. 

CAUSES. 

One of the principal causes, perhaps, is dyspnoea, from what- 
ever source arising. All violent and habitual exercise. Rheum- 
atism, which, by the irritation it maintains in the heart, invites 
an afflux of blood to it, conducive to an excess of nutrition. 
This nutrition, being vitiated by the existing morbid action, 
leads to the structural derangements incident to the case. 

DIAGNOSIS. 

IN GENERAL HYPERTROPHY, a rare event, physical 
exploration reveals only violent action of the heart, and dulness 
of sound on percussion. 

PARTIAL HYPERTROPHY, — 1. Of the left ventricle. 
This is the most common position of partial hypertrophy. 
Denoted, through the hand, and auscultation, by a very strong 
impulse between the cartilages of the fifth and seventh ribs, to 
which the strokes of the heart are confined ; and here the sound 
from percussion is dull. Impulse of the ventricle lengthened ; 
that of the auricle shortened. 

2. Of the right ventricle. Stroke perceived most plainly at 
the bottom of the sternum. The resonance is duller, also, in 
this position. Hypertrophy of the left side is more apt to induce 



HYPERTROPHY OF THE HEART 1Q1 

diseases, especially apoplexy, of the brain; while hypertrophy 
of the right, rather implicates the lungs. 

Concentric hypertrophy. Denoted by the dulness and ob- 
scurity of the heart's sounds, and their limitation to the precor- 
dial region. 

Eccentric hypertrophy. Denoted by clearness of sound, and 
its diffusion over nearly the whole chest. 

Hypertrophy is, in general, more easily distinguished than 
other cardiac affections. It is indicated by the fulness of the 
precordial region. From dropsy of the pericardial or pleural 
sac, which also evince this fulness, it may by many symptoms 
be discriminated. 

PROGNOSIS. 

By proper and early treatment, the disease is usually cured. 
It may at other times be so checked, that the patient may live 
to old age, without any serious inconvenience. Children are 
apt to outgrow it. 

The disease sometimes proves fatal from the supervention of 
cerebral or pulmonary apoplexy, or from hemorrhagic or 
hydropic effusions. 

AUTOPSIC APPEARANCES. 

The heart may increase in size three, or four times, or from 
eight or nine ounces it may even weigh as many pounds. The 
substance of the heart is redder than natural, and the coronary 
arteries are turgid. The external and internal surfaces occa- 
sionally exhibit evidences of inflammation. 

PATHOLOGY. 

Hypertrophy may result from healthy nutrition carried to an 
exaggerated degree. This state is occasioned by violent and 
protracted exercise of the organ, which enlarges under such 
circumstances like any other muscle of the body. 



102 DISEASES OF THE CIRCULATORY SYSTEM. 

Or, it may arise from inflammation, particularly rheumatic. 
In this case the organization is vitiated. 

TREATMENT. 

The same with that of carditis. Venesection and low living 
should not be carried to the extent of producing nervous irrita- 
bility and vitiation of the blood, which will not fail to aggravate 
this, in common with other cardiac affections. It is highly im- 
portant that sanguification should be well performed. 

Calomel, with the various narcotics, should succeed active 
measures. The iodine, much lauded, deserves a fair trial. 



DILATATION OF THE HEART. 



This state consists in an expansion of the cavities of the heart, 
with a preservation of the original thickness of the walls, or an 
attenuation of them. 

It is generally found in weak constitutions, or in persons 
of impaired health. The symptoms are consequently much 
modified and complicated by associate affections. 

SYMPTOMS. 

Early in the attack, where this is slight, and the system in a 
state of tolerable integrity, the disease is difficult of recognition. 

A sense of weight and uneasiness in the precordial region, 
or more extensively ; feeble palpitations ; pulse generally soft, 
small, and slow ; frequent and violent dyspnoea, with cough and 
copious expectorations, as in bronchitis, or humoral asthma; 
face pale and waxy, though occasionally livid, and the ex- 
tremities cold ; turgescency of the veins, particularly the ex- 
ternal jugular, and consequent on this congestion, haemorrhages, 
and dropsies ; senses and mental faculties obtuse ; headaches, 
apparently from fulness ; and sometimes stupor, convulsions, or 
apoplexy. 

The disease is not always so violent as has been represented; 
some of the most severe affections occurring only during the 
paroxysms, to which the disease is very liable. 

CAUSES. 

Whatever seriously and permanently impedes the circulation 
— as valvular disease of the heart, or arteries, or obstructions 



104 DISEASES OF THE CIRCULATORY SYSTEM. 

in the lungs, liver, &c. Whatever disturbs the heart's action, 
particularly a vitiated state of the blood. 

But, in addition, there must be a predisposition in the organ 
to such alteration. 



DIAGNOSIS. 

Sometimes difficult, when the case is embarrassed with com- 
plications. Distinguish it 

F R M H Y P E R T R P H Y, by the passive nature of its symp- 
toms. 

FROM ENGORGEMENT OF THE CAVITIES OF THE 
HEART, by the less round, equable, compressible distension of 
the precordial region, and by its permanency. 

FROM NERVOUS IRRITATION, by its permanency. 

But it is necessary in these cases, to collate all the symptoms. 

Respecting the reputed physical signs in this affection, Dr. 
Chapman is convinced that some prove nothing very decisive, 
and that the rest are fallacious. 

PROGNOSIS. 

A dangerous and intractable disease, particularly when con- 
nected with contamination of body, or the destructive lesions to 
be mentioned. 

AUTOPSIC APPEARANCES. 

Increased size of the heart; paleness and flabbiness, or soft- 
ening of its substance ; attenuation of its walls ; disease of the 
valves, septum, and columnse carneae. These changes may be 
universal, or embrace only a particular auricle or ventricle. 

Besides, we meet with a multitude of lesions of the lungs 
and abdominal viscera. 



DILATATION OF THE HEART. 105 

< 

PATHOLOGY. 

Dilatation is immediately owing to deficiency in the muscular 
power of the heart, and obstruction in the circulation, inducing 
accumulations of blood in the cavities of that organ, whereby 
through mechanical pressure the cavities are amplified, and the 
parietes attenuated. 

TREATMExNT. 

In curable cases the treatment must be directed to the affec- 
tions from which they originate, and by which they are aggra- 
vated. 

But the dilatation being inveterately fixed by incurable affec- 
tions of the heart, or other organs, we may hope only to alle- 
viate distress ; and this may be effected to a great degree. 

The leading indication is to preserve the general health. 

The tone of the system should be sustained by tonics, and a 
nutritive, digestible diet, and a residence in the country, espe- 
cially near the sea-shore. The strictest prophylaxis should be 
observed. Nervous irritation should be calmed by a stimulating 
pediluvium, and a soothing nervine or an opiate. These mea- 
sures not answering, the irritation will be probably reduced by 
cupping between the shoulders, and counter-irritation on the 
breast. Inflammation of the heart or other organs occurring, 
the usual remedies should be employed. 

Dr. Chapman has relieved the heart in a desperate paroxysm 
of exgorgemext, by the free and rapid abstraction of blood from 
the arm. This course, however, may not always be admissible. 



ATROPHY OF THE HEART. 



SYMPTOMS. 

Action of the heart very feeble, propensity to syncope, and 
the characteristics of the general pathological condition with 
which the cardiac disease is associated. 

CAUSES. 

Whatever produces a general marasmus of the body, the 
pressure of liquid effused into the pericardium, ossification of 
the coronary arteries, 

DIAGNOSIS. 

The disease cannot be certainly determined. 

PROGNOSIS. 

Commonly fatal. 

AUTOPSIC APPEARANCE. 

The heart has been found diminished to half its normal size, 
and wrinkled. 

PATHOLOGY AND TREATMENT. 

The opposite to those of hypertrophy. 



RUPTURE OF THE HEART. 



SYMPTOMS. 

These may be those of the pathological condition of which 
it is the effect ; though sometimes the rupture occurs without 
any previous symptoms. 

CAUSES. 

Occurs most among males and old people. The rupture is 
immediately excited by whatever produces strong action of the 
heart. 

DIAGNOSIS. 

Distinguished from cerebral apoplexy, by the instantaneous- 
ness of death, and pallidness of the countenance. 

PROGNOSIS. 

Nearly always fatal, — perhaps, when the rupture extends 
throughout thew hole thickness, always so. 

AUTOPSIC APPEARANCES. 

Besides the rupture, we may discover ulcers, softenings, par- 
tial atrophy, or partial hypertrophy. 

TREATMENT. 

Incurable. 



AFFECTIONS OF THE VALVES. 



Most common on the left side. 

SYMPTOMS. 

Not very peculiar. Generally, irregularity of the heart's ac- 
tion ; variable pulse ; weight, or pain in the prcecordia ; dyspnoea, 
cough, and expectoration ; venous congestion and its conse- 
quences. 

These symptoms aggravated greatly by mental or bodily 
excitement ; and no permanent ease is enjoyed even in a state 
of repose, the sleep being disturbed by agitative dreams. 

Life is terminated by sudden suspension of the heart's action, 
by pulmonary or cerebral apoplexy, and in various other ways. 

CAUSES. 

Over-action of the heart, and the ordinary causes of inflam- 
mation and perverted nutrition. 

DIAGNOSIS. 

Very difficult. This is rendered the more so from the usual 
complication, either as cause or effect, of some other organic 
disease, or of endocarditis. 

Auscultation, which has been extolled by some stethoscopists 
as highly diagnostic, is declared by others to be very fallacious. 
The last is the opinion of Stokes and Graves, But supposing 
that the exact lesion could by such means be determined, what 
advantage would be gained ? inasmuch as the diagnosis can 
only be formed when the affection has arrived to such maturity 
as to preclude the hope of relief. 






AFFECTIONS OF THE VALVES. 109 

PROGNOSIS. 

Always formidable, though, taken in the commencement, and 
where it is dependent on mere thickening from chronic inflam- 
mation, it may be removed. 

AUTOPSIC APPEARANCES. 

A part or the whole of the valves are found altered in shape, 
and, in cases of long standing, converted from mere thickening 
into fibro-cartilage, cartilage, or osseous or calcareous substance. 
The aperture is sometimes much contracted by the altered form 
of the valve. 

Vegetations may also exist along the basis, and free margins 
of the valves. Besides, there often co-exist other organic 
changes in the heart and other organs. 

PATHOLOGY. 

When the lesion consists merely in thickening, or consolida- 
tion of tissue, Dr. Chapman believes it to result from inflam- 
mation ; but when the substance is entirely new, he refers it to 
a distemperature of the nutritive process. But the latter may 
itself proceed from an inflammatory condition. How the im- 
peded circulation and other effects are produced, requires no 
explanation. 

TREATMENT. 

For this subject, Dr. Chapman refers to the Treatment of 
Hypertrophy, and of Dilatation, to be here employed according 
to the indication. 

In consideration of the great similarity of the treatment to be 
pursued in nearly all cases of organic disease of the heart, and 
of the incurability of others, Dr. Chapman animadverts on the 
futility of those who lay such undue stress, as it is now the 
fashion to do, upon the anatomical characters, the pathology, 
and the minute diagnosis of such diseases. 



NERVOUS AFFECTIONS OF THE HEART. 

PALPITATIONS. 

May be more violent than palpitations from organic disease. 

CAUSES. 

Either a nervous or sanguine temperament, either a full or an 
anaemic condition, exhibits a predisposition. 

As exciting causes of temporary palpitations, may be enume- 
rated mental agitation, physical exertion, stimulants, indigesti- 
ble food, the habitual use of opium, or of tobacco in any form. 
Chronic palpitations generally arise from an irritation derived 
from some of the abdominal or other viscera, spinal irritation, 
hyperemia, or anasmia. 

DIAGNOSIS. 

Quick, strong, irregular action of the heart and pulse, which 
is very apt to be intermittent ; a sense of agitation throughout 
the epigastrium, and in the head ; palpitations experienced more 
in repose than when up and moving about; sometimes con- 
tinued the greater part of the night, increased by lying on the left 
side; often gastric disorder; a disposition to urinate, the dis- 
charge being pellucid and copious. 

Again, we may conduct a diagnosis by exclusion — dis- 
covering that the palpitations do not proceed from any par- 
ticular organic disease. 

In nervous palpitations, the impulse, apparently great, is 
really moderate, and rarely repels the hand when placed over 
the cardiac region. 

The effect of antispasmodics is also very diagnostic. 



PALPITATIONS. l\\ 



PROGNOSIS. 

These palpitations generally do not lead to any serious con- 
sequence. 

AUTOPSIC APPEARANCES. 

Sometimes, perhaps, hypertrophy, or dilatation, as an effect, 
and serious disease of the chylopoietic viscera, or lungs, as a 
cause. 

PATHOLOGY. 

The palpitations, at first merely irritative, may afterwards, 
as we are assured, lead to disorganization of the heart 

TREATMENT. 

The palpitation being brought on suddenly from moral emo- 
tion, or inordinate physical exercise, the individual should rest 
for some time, and may in addition resort to a nervine in the 
former, and venesection in the latter case. Proceeding from 
gastric disorder, employ an emetic, or, if sufficient, an antacid. 

In the chronic form, we must address our treatment to the 
disorder, whatever it may be, of which the palpitation is an 
effect. The paroxysms are to be appeased when they occur. 



MEDICAL DISEASES OF THE 
BLOOD-VESSELS. 

ACUTE ARTERITIS, OR INFLAMMATION 
OF THE ARTERIES. 

SYMPTOMS. 

The disease, as an idiopathic affection, being very rare, its 
symptoms are not very well understood. They are said, how- 
ever, to consist in a vehemence of pulsation in the phlogosed 
vessel ; a sense of heat and pain along its course, with a corre- 
sponding streak of redness ; extreme pain on pressure. 

As general symptoms, we have extreme restlessness, nausea 
and faintness, and where the aorta or pulmonary artery is 
concerned, dyspnoea, cough, and thoracic pain are apt to be 
present. 

The fever, at first perhaps ardent, is soon converted into one 
of a typhoid type. 

CAUSES. 

Probably those of cardiac inflammation. More generally it 
proceeds from an extension of pulmonary, cardiac, or abdomi- 
nal inflammation. 

DIAGNOSIS. 

There can be no positive discrimination of internal arteritis. 



ARTERITIS. U3 



PROGNOSIS. 



The severer forms of the disease often fatal. The chief 
danger proceeds from the obliteration of the artery from effused 
lymph, or from the diffusion of the pus secreted by it, or soften- 
ing, or other organic change of its texture. 

AUTOPSIC APPEARANCES. 

The most common are redness of the interior membrane, in- 
terspersed with white spots; occasional extravasations of lymph, 
and depositions of pus; and thickening, ramollescence, and ulcera- 
tion of the arterial surface. In phlogosis of the great arteries 
within the chest, these appearances may be extended to the 
heart. Indeed the red staining sometimes pervades the vessels ; 
and hence has probably arisen the erroneous notion of fever 
being dependent on arteritis. 

PATHOLOGY. 

Mere redness is not to be regarded as a proof of previous in- 
flammation, since this appearance often takes place after death, 
particularly in typhoid cases, and where the blood is preterna- 
turally fluid. 

TREATMENT 

Corresponds to that of similar inflammation of the heart. 



8 



114 DISEASES OF THE CIRCULATORY SYSTEM. 

The arteries are subject to a CHRONIC INFLAMMATION, 
which, though some authorities constitute it the more common 
affection, is, in the opinion of Dr. Chapman, a comparatively 
rare event. By those who hold the other notion, it is probably 
made to include — 



DEGENERATIONS OF ARTERIES. 

These consist of extraneous deposits of fibrous, steatomatous, 
cartilaginous, calcareous, osseous, and other matters. From 
such metamorphosis no artery is exempt, but the remarks are 
here confined to the arteries of the cavities. The artery most 
usually thus affected is the aorta, and next, are the cerebral 
arteries, by which is laid, as is now believed, the foundation, in 
the majority of cases of cerebral apoplexy, and some of epilepsy. 
The pulmonary artery is seldom thus involved. 

SYMPTO MS. 

The disease is seldom betrayed by any marked symptoms, 
until it has reached a considerable height. Subsequently we 
have that sort of distress, and other effects, which proceed from 
an embarrassed circulation. 

CAUSES. 

The affection most incident to old age, — particularly ossifica- 
tion. Other causes are the long prevalence of gout, or rheu- 
matism, syphilis, the abuse of mercury, intemperance in eating 
or drinking, and perhaps hereditary influence. But often these 
changes occur without any appreciable cause. 

DIAGNOSIS. 

We cannot, either by symptoms or physical signs, diagnosti- 
cate this disease with certainty. 



DEGENERATIONS OF ARTERIES. U5 

PROGNOSIS. 

Generally incurable. 

AUTOPSIC APPEARANCES. 

The deposit is between the coats. Sometimes several kinds 
of degeneration are exhibited at the same time, — the case pro- 
gressing from the softer to the harder deposits. Of the aorta, 
the beginning and arch are mostly affected. 

PATHOLOGY. 

When consolidation merely has taken place in consequence 
of the infiltration of lymph, or albumen, it is the effect of inflam- 
mation ; but where the identity of structure has been lost, then 
the change is referable to a vitiation of the nutritive process. 

TREATMENT. 

At an advanced period, little can be anticipated, besides mere 
palliation. The measures are not materially different from those 
to be pursued in organic diseases of the heart. 



ANEURISM OF THE ARTERIES. 



By aneurism is meant a dilatation of an artery. This may 
occur from the simultaneous distension of all the coats, or by 
some of them giving way, causing an extravasation of blood, 
or by a solution of continuity in the interior coats, while the 
outer one maintains its integrity. These forms receive the 
respective names, true, false, and mixed aneurism. 

Here will be considered aneurism of the internal vessels only. 
They are all liable to the affection, but the aorta being pre- 
eminently so, will be mainly regarded. The lesion is nearly 
always found either in the ascending portion or arch. 

SYMPTOMS. 

Being deep-seated and small, it is said to be not detectible ; 
and death may give the first intimation of disease. Being, 
however, more developed, the symptoms are, cachectic aspect, 
palpitations or other strong pulsations, dyspnoea, cough, dis- 
turbed sleep, a tendency to syncope, irregular distributions of 
blood, creative of congestions, and sometimes lividity of coun- 
tenance, passive haemorrhage, and serous effusions. These 
symptoms, though common to many of the cardiac affections, 
are apt here to be more intense. 

CAUSES. 

Like those of associated cardiac affections, and spontaneous 
aneurism in external arteries. 



ANEURISM OF THE ARTERIES. 117 



DIAGNOSIS. 

Very pathognomonic when it exists, is a tumour-like promi- 
nence in the situation of the aneurism, with a heaving pulsation. 

The paroxysmal occurrence of the symptoms best distin- 
guishes the nervous affections which resemble aneurism in their 
manifestations. 

Percussion at the top of the sternum may elicit a dull sound, 
and through the stethoscope applied to the same region, we may 
discover a loud, rough, or abrupt bellows sound, or a purring 
murmur, or a slight whizzing. 



PROGNOSIS. 

Incurable by art, aneurism of internal vessels, and even the 
aorta, is occasionally cured by nature, from the coagulation of 
blood in the sac, and its ultimate conversion into a small dense 
tumeroid mass. 

AUTOPSIC APPEARANCES. 

The artery having been ruptured, we discover the blood in 
one or more of the contiguous organs. The parietes may be 
found either attenuated or thickened. The rupture may occur 
from the tenuity of the parietes or from ulceration. When the 
aneurism is large, surrounding parts are removed by absorption, 
excited by the pressure. Even bone itself cannot resist. Ossi- 
fication or other degenerations in other parts of the artery may 
be associated. The pulmonary artery is rarely affected. 



PATHOLOGY. 

From a loss of contractility, the pressure of the blood gives 
rise to permanent dilatation. 



118 DISEASES OF THE CIRCULATORY SYSTEM. 



TREATMENT. 

The plan suggested two hundred years ago by Valsalva, and 
which still receives the chief suffrage of the profession, is to 
bleed the patient very frequently and subject him to the most 
reductive regimen. But Dr. Chapman rejects the plan for the 
following reasons. 1. A cure being only effected by the 
retardation of the blood in the aneurism from the roughness of 
its interior surface, cannot be attained in true aneurisms, in 
which the lining membrane is smooth. But nine-tenths of the 
cases are true aneurism. It can, therefore, hardly be advisable 
to subject the patient to such harassing and deleterious mea- 
sures, when, at best, there is hope in only one case in ten. 2. 
It does not appear that in the instances in which a cure has 
been spontaneously effected, the system has been remarkably 
low. 3. The result of excessive bleeding and inordinate absti- 
nence is excitement rather than serenity of the circulation. 
4. The blood becomes so impoverished that it is inadequate to 
the deposit of a coagulum. 5. The coats of the artery lose 
tone, and become, in consequence, still less able to resist the 
morbid process, by which the aneurism is formed. 

In addition to the treatment mentioned, it is common for 
practitioners to rely upon the acetate of lead. But of this 
remedy Dr. Chapman is equally distrustful. 

Discarding all expectation of a radical cure, he confines his 
efforts to the arrestation of the progress of the lesion, and to 
render it as tolerable as possible. These ends are accomplished 
by calming the circulation. For this purpose he resorts to 
venesection and purging, when necessary — digitalis in the in- 
tervals, a moderate amount of nutritious food, and the careful 
avoidance of constipation, exercise, and whatever else may 
excite the pulse. This treatment corresponds with that already 
suggested for several of the organic diseases of the heart. 



INFLAMMATION OF THE VEINS, 
OR PHLEBITIS. 



A disease of recent investigation. 



SYMPTOMS. 



Exhibited in a superficial vessel, there is pain, vastly in- 
creased on pressure, with swelling, stiffness, and a streak of 
redness along its course. It is an affection proceeding nearly 
always in the direction of the heart. Constitutional disturbance 
is soon betrayed by febrile and other manifestations. Located 
in a limb, this may be more than double its natural size, while 
the skin is tight, smooth, and white. The fever may become 
exceedingly typhoid. There also exists chills or rigors, and 
rheumatic-like aches in the joints, or wandering about the 
cavities of the body. 

The case above delineated is one of marked violence, which* 
unabated by our remedies, has progressed probably to the sup- 
puration of the vein. The description relates particularly to 
the phlebitis induced by venesection. 

The disease called phlegmasia alba dolens, Dr. Chapman 
thinks has been improperly attributed to inflammation of the 
veins. 

Deep-seated veins enjoy no immunity from such attacks ; but 
of the symptoms by which their phlogosed condition is marked, 
we have no satisfactory knowledge. 

Dr. Chapman is disposed to believe that the abscesses in the 
lungs, liver, and other parts of the body, which so frequently 
accompany phlebitis, are not, as is supposed, dependent upon 



120 DISEASES OF THE CIRCULATORY SYSTEM. 

the deposit of pus, which has been secreted by the phlogosed 
vein, and transmitted with the current of blood, but that they 
are dependent upon the sympathetic irritation, by which ab- 
scesses are so often formed in low diseases. 



CAUSES. 

Nearly always arises from mechanical injury. Dr. Chapman 
believes that it is never occasioned directly by a virus; thinking, 
however, that the vein may become involved in the condition 
of the adjacent tissues, when they are inflamed by the applica- 
tion of a virus. The instances of tumefaction from the inser- 
tion of a virus, he presumes to be an affection of the lymphatics. 

There are certain times when phlebitis is particularly com- 
mon. In certain constitutions, also, the slightest scratch will 
give rise to this result. 

DIAGNOSIS. 

Inflammation of the interior veins can never perhaps be cer- 
tainly determined. The diagnosis from inflammation of the lym- 
phatics, and of the cellular tissue, can only be made out, either 
before or after the period of excessive tumefaction ; when the 
phlogosed vein may be perceived running in a tortuous course. 
During the height of this affection, or phlogosis of the lympha- 
tics, the polished rotundity of surface, from an implication of 
the cellular tissue, is the same with that of 'primary inflamma- 
tion of that tissue. 

PROGNOSIS. 

Favourable when the disease is early attended to; the reverse 
when the inflammation has become intense. 

AUTOPSIC APPEARANCES. 

Redness of the vein in specks, or striated, or arborescent — 
continuous, or in patches; effusion of lymph, sometimes agglu- 
tinating the sides of the vessel; suppuration, and even ulceration. 



INFLAMMATION O F T H E V E I N S. j^ 1 

Deposits, in various parts of the body, of pus, varying in size 
from a pea, to a large peach. The organ is usuaHy found in- 
flamed immediately around the deposit. 

PATHOLOGY. 

Dr. Chapman accounts for the constitutional disturbance 
which takes place before suppuration, by supposing that the 
whole venous system experiences a sympathetic irritation. 
Upon the occurrence of suppuration, we may suppose the dif- 
fusion of the pus by the current of blood, to operate in the pro- 
duction of the adynamic state, which characterizes a more 
advanced period of the disease. 

TREATMENT. 

The limb should be put into a state of Absolute Rest, 

Venesectio n. — Only when the febrile excitement is very high. 
It is apt to be followed by a fresh attack of phlebitis. 

Leeches. — To be repeatedly applied along the course of the 
vein. 

Emollient Cataplasms. 

A B 1 i S t e r. — Of extraordinary value. A narrow slip of the 
epispastic plaster should be placed along the course of the vein, 
as far as it appears inflamed, having an opening in it at the 
orifice, over which a soft poultice is to be placed; and the 
blister having drawm, is to be kept freely discharging. 

Purgatives and Arterial Sedatives. 

Calomel, Opium, and Ipecacuanha. — Dr. Chapman re- 
lies much upon the promotion, at this stage, of perspiration. 
Should pain and restlessness be prominent, he directs the Dover's 
powder largely. 

Pus having formed, the best hope of preventing its transmis- 
sion to the system is offered by the ligature of the vein ; but 
this might do more harm than good; and it has never been 
tried. Compression of the vein to an extent that can be tole- 
rated, or cutting the vein, is inadequate to arrest the blood. 



DISEASES OF THE ALIMENTARY SYSTEM. 



ACUTE INFLAMMATION OF THE THROAT. 

This is generally most displayed in phlogosis of the tonsils. 
The latter has received the names of cynanche tonsillaris — an- 
gina tonsillaris — tonsillitis — and the common names, sore throat, 
and quinsy. 

SYMPTOMS. 

Fever, pain, hnskiness, scriatus, increase of saliva, heavily 
coated tongue, and difficulty of deglutition. In addition, the 
uvula, palatine lining, eustachian tubes, and interior of the ear 
may become involved. Under such circumstances, there may 
be earache, and an inability to swallow or articulate. The 
inflammation may also extend to the tongue, pharynx, oesopha- 
gus, and larynx. Glossitis, or inflammation of the tongue, is 
evinced by ocular demonstration. In pharyngitis, and oesopha- 
gitis, there is pain on pressure, and regurgitation of whatever is 
attempted to be swallowed. 

A person who has had several attacks of tonsillitis, may have 
it without any constitutional implication. This is true, also, 
when the habit is scrofulous. But, ordinarily, the disease soon 
terminates in resolution, suppuration, or induration. In some 
cases, the phlogosis is very superficial and diffusive, like that of 
erysipelas. 

CAUSES. 

Cold. The erysipelatous variety Dr. Chapman believes to 
proceed from gastric disorder. 



INFLAMMATION OF THE THROAT. 123 

Malignant or pellicular sore throat seems to be merely scar- 
latina, without the cutaneous eruption, and to the treatise on 
that subject the reader is referred. 



PROGNOSIS. 

Favourable. Death, however, may occur suddenly from 
suffocation. 

TREATMENT. 

The disease being yet in its forming stage, may be sometimes 
checked by a gargle of the infusion of capsicum, or a solution 
of salt in vinegar* or brandy. The nitrate of silver, or burnt 
alum, is recommended. External rubefacients, and a flannel 
covering to the neck, should be also employed. 

These measures failing, we may resort to 

An Emetic. 

A Purgative and subsequent laxatives. 

Venesection, when required by great excitement. 

Topical Bleeding. 

Poultices. 

Blisters, in violent cases. 

Inhalations of heated vapour of water, or of water and 
vinegar. 

Stimulating gargles should be withheld in the active stage. 

Suppuration having occurred, as may be known by the yel- 
lowish appearance of the tumour, and the throbbings and the 
disposition' to rigors, it will be right to open the abscess. Sub- 
sequently, the patient may use mild gargles. 

In glossitis, pharyngitis, oesophagitis, or laryngitis, it is neces- 
sary to use depletory and other antiphlogistic measures with 
the greatest vigour. When the tongue is badly inflamed, the 
tension should be removed by deep incisions, and leeches may 
be applied to the lower surface. There being an abscess in the 
pharynx, or oesophagus, it may be ruptured by the throat lancet 
or the bougie, or by vomiting. 

The erysipelatous variety is to be treated by an emetic, a mer- 
curial purge, leeches, vesication, and detergent gargles. 



124 DISEASES OF THE ALIMENTARY SYSTEM. 

A typhoid state supervening, as it is sometimes said to do, 
stimulants and the other treatment of malignant scarlatina may 
be required. 

Torpid tumours are to be removed by the application of burnt 
alum, or by leeching, vesication, and discutient gargles. 

Elongated uvula, when attenuated and relaxed, or when 
turgid with blood, or oedematous, should be treated with the 
application of burnt alum ; but being intermediate to these con- 
ditions, with leeching and emetics. 

Enlargement of the tonsils demands excision, 



CHRONIC INFLAMMATION OF THE THROAT 



SYMPTOMS. 

PRIMARY. — Redness, diffused or in streaks or patches, and 
injection of vessels. 

ADVANCED.— Ulceration. 

CAUSES. 

The consequence of the ill-cured acute affection, of an ori- 
ginal disease arising from the same causes with the acute, more 
slowly operating. 

TREATMENT. 

Any activity of phlogosis existing, the means just indicated 
must be resorted to. 

There being mere congestion, the vessels may be emptied by 
local bleeding and vesication ; and the part may then be sub- 
jected to astringent or tonic applications. Ulcerations should 
be touched with lunar caustic, or treated with gargles. 

The disease depending upon constitutional vitiation, the treat- 
ment will, of course, depend upon the peculiar nature of that 
vitiation. Yet, in general, it may be said that an alterative course 
of blue pill, moderate purging, an occasional emetic when the 
ulcers are very foul, or the general secretions depraved or de- 
fective, and sarsaparilla, are valuable remedies. 

There is a condition in which, with dryness and huskiness of 
the fauces, slight teasing cough, and hawkings, the throat is 
pallid and relaxed, but the constitution is sound. Dr. Chapman 
believing this state to result from defective innervation, directs 
topical bleeding and counter-irritation to the back of the neck, 
and seldom fails in curing it. 



DYSPHAGIA, OR DIFFICULTY OF 
SWALLOWING. 



This may result, first, from organic disease of some kind, or, 
secondly, from disorder of the cerebro-spinal axis, either original, 
or the result of irritations in the alimentary canal, or elsewhere. 
The treatment of the second variety, is to remove these irritations 
when they exist; to employ local bleeding and counter-irritation 
to the back of the neck, nauseants in some instances, the cau- 
tious administration of mercury with a view to its constitutional 
effect, when there is a state of excitement, but dry cups, coun- 
ter-irritants, antispasmodics, and tonics, when there is a state 
of enervation. Spasmodic stricture of the oesophagus may be 
distinguished from organic, by observing that it is sometimes 
remitted, and especially upon the introduction of a bougie. 

The oesophagus is subject to chronic inflammation and ulcera- 
tion. But these incidents are very rare. 

CHRONIC GLOSSITIS. 

This is connected with enlargement. It may terminate in 
.esclution, suppuration, or ulceration. Similar enlargement of 
the lips may be conjoined. The treatment consists in correcting 
the depravation of the digestive and nutritive organs, on which 
the disease usually depends, or whatever constitutional vitiation 
may exist ; repeated leeching ; poultices to the lips, when af- 
fected, and the liberal exhibition of cicuta. This state is some- 
times a scrofulous disorder. 



INFLAMMATION OF THE PAROTID, 
OR MUMPS. 



May be either common or specific. The latter form, called 
cynanche parotidea, parotitis, or mumps. The former variety 
so nearly resembles tonsillitis in nature and treatment as to 
preclude the necessity of distinct description. 

Parotitis is exhibited by a pain and swelling in one or both 
parotid glands, involving the submaxillary, and accompanied by 
fever. It is subject to metastasis to the testis in males, and the 
mamma in females. 

CAUSES. 

An epidemic influence, or perhaps contagion. It resembles 
contagious diseases, certainly, in there being an immunity 
against a second attack. 

DIAGNOSIS. 

Differs from ordinary inflammation of the parotid, in the 
greater rapidity of swelling, the tendency to spontaneous subsi- 
dence, the difficulty of mastication, and the peculiar painfulness 
in masticating sweet substances— in a more general constitu- 
tional disturbance, its disposition to metastasis, and its usually 
prevailing epidemically. 

PROGNOSIS. 

Not serious except when metastatic. It is milder and less 
prone to metastasis in early life. 



128 DISEASES OF THE ALIMENTARY SYSTEM. 



TREATMENT. 

In mild cases, the patient should keep within-doors, protect 
the tumour by a flannel bandage, take a laxative, and restrict 
his diet. The part may be bathed with a lotion of laudanum, 
sweet oil, and brandy. 

But in violent instances, the antiphlogistic system should be 
fully carried out. The influence of cold must be carefully 
guarded against. 

Driven to the testicle, it may create much pain, swelling, 
fever, and even delirium, The testicle may also in consequence 
entirely waste away. We should encourage a return to the 
parotid by moderate warmth, and treat the disease as hernia 
humoralis, — that is, by common depletory and sedative mea- 
sures, and when the stomach is much disordered, by an emetic. 

When metastasis to the mamma has taken place, we should 
adopt a similar practice. Should it become inveterate, we 
may direct the frequent application of leeches, mild discutients, 
a low vegetable diet, an alterative course of mercury, and a 
succession of emetics. The affection may degenerate into 
scirrhus. 



DYSENTERIA OR DYSENTERY. 



INFLAMMATORY FORM. 

SYMPTOMS. 

That variety arising from cold, so nearly resembles colitis, 
already described, as to require no further exhibition. 

INCEPTIV E. — An attack in warm weather is usually intro- 
duced by anorexia, epigastric fulness, furred tongue, thirst, 
bitter taste, nausea, and sometimes vomiting, uneasiness in the 
abdomen, dry skin, muscular soreness and debility ; or it is in- 
troduced directly by a chill and fever. 

MORE ADVANCED.— After the constitutional disturbance, 
follow griping, and a propensity to go to stool ; large, feculent, 
or watery discharges for a time, and then small ones, consisting 
of mucus only, or tinged with blood ; a sense of weight or 
dragging in the lower part of the abdomen ; and either fugitive 
pain, or permanent tenderness. 

But often the local affection supervenes first; and the system 
may sympathize very little throughout the case, — certainly not 
to the extent of a fever. 

STILL MORE A D V A N C E D.— Stools more frequent, and 
painful ; every evacuation being attended with an aggravation 
of tormina and tenesmus, and a good deal of borborygmi or 
rumbling from flatulence. Occasional prolapsus of the intestine. 
The discharges sometimes become like cheese ; or they may be 
purely hemorrhagic. Again, there may be evacuated a sub- 

9 



130 DISEASES OF THE ALIMENTARY SYSTEM. 

stance like flesh, composed of coagulable lymph, or impacted 
mucus reddened with blood ; or matter resembling the mucous 
coat of the bowels. The scybalas, which are in some instances 
discharged, consist of hardened balls of faeces. Little or no 
bile is ever apparent in the stools. Although there be fever, the 
pulse is seldom full or active, however tense and corded it 
may be. 

FINAL STAGE. — A depression of strength; cold skin; some- 
times, petechia?, or vibices ; great soreness and tension of the 
epigastrium ; feeble pulse; a singularly altered, and often corpse- 
like countenance. 

These symptoms may be varied by a concentration of the 
disease in a particular section of the bowels, or a particular coat, 
or by the complication of other affections. 

CAUSES. 

Dysentery was once ascribed almost exlusively to contagion. 
The notion of its ordinary production in this way is now pretty 
much abandoned. But this question will be discussed in the 
consideration of the congestive form of the disease. 

Miasmata, an excess of heat, sudden variations of temperature ; 
a damp, heavy, murky atmosphere; a. calcareous soil, epidemic 
influence, and checked perspiration, by whatever cause pro- 
duced. Certain ingesta, among which may be mentioned crude 
fruit, and unwholesome vegetables, and particularly, putrid or 
spoiled aliment. A sudden change from an animal to vege- 
table diet, or the reverse ; or from salted to fresh provisions, or 
the opposite. Acid beverages, stagnant water. 

With us, dysentery is mostly a disease of the country ; and 
of simultaneous # prevalence with autumnal fevers, — the former 
occurring in high situations, and the latter in the contiguous 
low grounds. 

DIAGNOSIS. 

The only disease with which dysentery is liable to be con- 



D Y S E N T E R I A, OR DYSENTERY. ] 3 [ 

founded, is diarrhoea; and here the treatment is so similar, that 
the discrimination is unimportant. 

PROGNOSIS. 

As the case is open and inflammatory, with a warm surface, 
and an active circulation, so will it prove manageable. 

FAVOURABLE S I G N S, are a discharge of mucus, or a mo- 
derate discharge of arterial blood at an early stage, bilious and 
natural stools, &c. 

There is a well-authenticated case, and another which has 
been seen by Dr. Chapman himself, in which recovery took 
place after the sloughing off of a large portion of intestine, which 
was evacuated. 

It is a most intractable disease, and when permitted to run 
to a far advanced stage, is very apt to prove fatal. 

AUTOPSIC APPEARANCES. 

Very similar to those already described as belonging to 
enteritis. 

The lesions are chiefly seated in the mucous coat of the large 
intestines, and, above all, the colon. The other coats are com- 
paratively little affected. In hot countries most of the abdomi- 
nal viscera are apt to share in the disease. The liver is espe- 
cially apt to be congested, and may be structurally affected. 

PATHOLOGY. 

Dysentery of the form now under consideration, is evidently 
an inflammation of the mucous tissue of the primse viae, parti- 
cularly of the large intestines. So long as it is insulated in the 
mucous tissue, there is prostration of strength, and discharges 
of mucus, variously coloured, or otherwise changed, with little 
or no pain. Extending to the muscular coat, tormina and tenes- 
mus are induced; and the darting, lancinating pain must be 
ascribed to an extension to the peritoneal coat. 



132 DISEASES OF THE ALIMENTARY SYSTEM. 

The skin being robbed of its fair proportion of excitement 
by the irritation of the interior, becomes cold and collapsed, 
until reaction takes place. Yet it finally relapses, when the 
case does not proceed well, into its former condition. 

The sympathetic fever is sometimes intermittent, though 
oftener remittent, or continued. 

The difference between dysentery and colitis, is like that 
between gastric fevers and a gastritis. The former is a general, 
proceeding from a local affection ; the latter is the same local 
affection unaccompanied by the general disorder. Dysentery 
is connected with greater depravation of the secretions. 

TREATMENT. 

In the form now before us, we are called on mainly to re- 
move inflammation with the spasm attending it, to procure a 
free evacuation of the alimentary canal, and restore the healthy 
secretions of it, the liver and the skin. 

Venesection, — When febrile reaction has taken place. It 
must be very free, or it will be nugatory. It must be, however, 
early resorted to, or it will not be admissible. The phlogosis 
of the mucous membrane of the large intestines is particularly 
rapid, and is prone to proceed very speedily to fatal disorgani- 
zations. Even within twenty-four hours, such changes may be 
wrought, as will forbid the use of the lancet. 

Leeches. 

Warm Fomentations, or Poultices. — Some recommend 
Cold applications. Those may be used which, upon a trial, 
suit the patient best ; Dr. Chapman, however, has not employed 
the cold, except in hasmorrhagic cases. 

Emetic s. — Dr. Chapman limits their employment to those 
instances in which there is a stomach loaded with irritating 
ingesta, or secretions, and here even, to the inchoative stage. 
Yet, when there is no active phlogosis of the stomach, he does 
not condemn their use on other occasions, since he has not had 
much experience with them, except when given in the circum- 
stances just mentioned. Zimmerman resorted to them often, 
during the course of the affection. 



DYSENTERIA, OR DYSENTERY. 133 

Ipecacuanha has been employed in the dose of a drachm, or 
more ; and for the prevention of vomiting, it is given in union 
with sixty drops of laudanum, and the supine position is main- 
tained. Its beneficial effects are said to be very striking. Dr. 
Chapman, however, reposes little faith in the practice. 

Purgatives, to cleanse the bowels of their oppressive or 
irritating contents. Castor oil is usually preferred, and may 
answer in the lenient forms of the disease. But to the dysen- 
teries of warm weather, mercurial purges are much better 
suited. It is well, sometimes, to combine the calomel with 
opium and ipecacuanha, by which the irritation is mitigated. 

Evacuations having now been freely made, we may substitute 
for calomel, the oil, or what sometimes answers better, the sul- 
phate of magnesia. 

Gamboge has been affirmed, on the ground of experience, to 
be a useful purgative. Cheyne also ascribes great efficacy to 
half an ounce of finely levigated cremor tartar, repeated every 
four or five hours. 

Even the mildest purgative sometimes excites the most dis- 
tressing spasm, or, from an exaltation of nervous irritability, 
passes directly through the bowels. Here an opiate should be 
conjoined, which really assists in the removal of irritating col- 
lections, and renders the discharge less painful. 

It is a good general rule, to proceed with purgation until 
natural, or, at least, essentially improved stools are manifested. 
It is easy to conceive how exceedingly annoying must be the 
acrid secretions which are incident to the affection. Still these 
very secretions are liable to be sustained by the irritation of our 
purgatives. The rule is, therefore, limited. 

Opiate s. — To obviate irritation, Dr. Chapman is accustomed 
to resort much earlier to the use of opiates, than is generally 
approved. Enlarged experience, however, has confirmed him 
in their early use. Having, in part, the wish to produce a deter- 
mination to the skin, he commonly directs opium in combina- 
tion with calomel and ipecacuanha, by which its virtues are 
much enhanced. 

It is a good plan to give laxatives during the day, and opiates 
at night. 



134 DISEASES OF THE ALIMENTARY SYSTEM. 

Coming to the conclusion that purgatives have been carried 
sufficiently far, we may resort, during the day, to a union of 
opium, ipecacuanha, and the blue mass. The usual effect of 
this is to give great comfort, and to restore the healthy secre- 
tions of the intestines, skin, and liver. Yet when there is a pre- 
dominance of tormina and tenesmus, and especially if attended 
with discharges of blood, pure or mixed with mucus, the opium 
may be more advantageously combined with the acetate of lead. 

Either of the preceding prescriptions, however, being given, 
an intermission is required occasionally, perhaps once in twenty- 
four hours, for the operation of some mild laxative. 

The following prescription, called the oleaginous mixture, is 
much used as a laxative, in such cases : 

R— 01. Ricini, gj. 
Gum. Arab. 3j. 
Saccbar. Alb. 3j. 
Tinct. Opii, gtts. xl. 
Aq. Menth. 3iij. 
M. 3ss. may be occasionally taken. 

In dysentery, particularly when it is seated chiefly in the 
rectum, injections of laudanum and mucilage will be very bene- 
ficial. A suppository of two or three grains of opium will 
sometimes be better retained. 

Tobacco injections and fomentations have been recommended. 
The former may be made of the strength of ten grains to six 
ounces of hot water — the whole of which may be injected. We 
ought to be very careful in the use of tobacco, on account of its 
sometimes fatally depressing effects. 

Cold barley water, or flaxseed mucilage, or melted lard, are 
very serviceable injections. Some prefer ice-water, which might 
well suit haemorrhagic cases. These are also well treated with 
the solution of acetate of lead. 

But, above all, Dr. Chapman recommends leeching around 
the verge of the anus, as being the best of all local measures, to 
relieve the pain and spasm. 

Active S we a tin g. — This, after the employment of due san- 



DYSENTERIA, OR DYSENTERY. 135 

guineous and other depletion, may be properly effected by the 
administration of the Dover's powder, and vapour bath. 

A Flannel Bandage from the hips to the axillae, has been 
said to be beneficial. 

Blisters. — The activity of the phlogosis having been deci- 
dedly subdued, these become quite useful. The skin having been 
reddened by the blister, the latter may be taken off, and a poul- 
tice substituted. 

Upon the occurrence of a sinking state, those stimulating 
remedies may be resorted to, which will be mentioned in the 
consideration of the congestive form. 

DTET, — Should consist exclusively of the mucilages. 



CONGESTIVE OR TYPHOID DYSENTERY. 



SYMPTOMS. 

The most prominent feature of this form is a want of reac- 
tion. The skin continues cold, damp, and mottled, or, as may 
happen, partially dry and heated ; the tongue loaded and dark ; 
and there is much gastric, and occasionally some cerebral 
disorder. 

Contracted under peculiar circumstances, the disease has re- 
ceived a modification partaking of the nature of scurvy. To 
many of the symptoms already detailed, are here added soft, 
spongy, livid gums, occasionally so ulcerated, that the teeth 
become loose and fall out ; the lips and mouth are livid, and the 
breath fetid ; while, more or less, over the whole body, though 
particularly on the extremities, large blue or purple spots are 
dispersed. 

CAUSES. 

The congestive species of the affection is principally met 
with in crowded, ill-ventilated places, — as in ships, hospitals, 
prisons, besieged towns, and camps. 

The cause to which, when thus appearing, it is generally 
assigned, is contagion. The effluvium is by some supposed to 
spring immediately from the excrementitious discharges ; while 
others suppose it to be the product of their putrefaction. There 
seems to be, however, no substantial demonstration of the 
truth of either of these theories. The probability is, that 
typhoid dysentery is the result of a contaminated atmosphere, 



CONGESTIVE OR TYPHOID DYSENTERY. 137 

acting at a time when there is a predisposition to dysenteric 
disease. 

Other causes are, epidemic influences, and those causes 
already enumerated as productive of the inflammatory variety. 

PROGNOSIS. 

Sometimes extremely intractable, and fatal. 

AUTOPSIC APPEARANCES. 

Generally, in place of the marks of active phlogosis, we 
meet with turgescency of the vessels of the intestines, with 
ecchymosis and softening of the mucous tissue, and perhaps 
gangrene of all the coats. Various other abdominal viscera 
are frequently involved, and sometimes the brain. 

PATHOLOGY. 

The peculiarity evidently consists in there being, instead of 
an actively inflammatory state, a congestive condition, with a 
tendency to rapid disorganization. 

TREATMENT. 

A low, collapsed state existing, the skin is to be excited by 
the Vapour Bath, Stimulating Frictions, Sinapisms, &c. 

Venesection. — Indicated by an increased warmth of skin, 
a rising of the pulse, and particularly by acuteness of pain. 

Cups, or Leeche s. — These may be used where venesection 
is inadmissible, and are our chief dependence for overcoming 
congestion. Leeches around the anus are highly useful, espe- 
cially when there are large sanguineous stools. 

Emetics, — Well suited to this form, even when the stomach 
is not loaded with irritating contents. The best of the class is 
the chloride of sodium. 

Mercury, — It is the custom in India to rely much upon the 
production of ptyalism. With this view some practitioners 



138 DISEASES OF THE ALIMENTARY SYSTEM. 

there, give it in the dose of a scruple several times a day. Dr. 
Chapman, however, usually directs one or more ordinary doses 
of calomel, according to the urgency of the occasion, to be 
hastened in their operation by the castor oil, or neutral salts, 
and then a combination of it with opium and ipecacuanha, in 
small and repeated doses. Now and then, he recurs to enemata 
and the other palliatives of suffering enumerated under the In- 
flammatory Form. 

Blisters. — To the abdomen, and extremities. 

Stimulant Diaphoretics here promise a great deal. 

More stimulating remedies may be henceforward demanded. 
Among these may be mentioned the carbonate of ammonia, the 
spiced wine, and oil of turpentine, which last is to be preferred 
in the passive haemorrhage incident to the disease. Other re- 
medies are the sulphate of quinia, charcoal to correct the fetor, 
infusion of capsicum by mouth, and by enema, and the nitric 
or nitro-muriatic acid in the scorbutic variety. 

DIE T, — In the early stage, should be like that in the inflam- 
matory form ; but when debility of the vital forces has super- 
vened, to the farinaceous articles may be added, wine, chicken, 
mutton, or beef tea. 

An intermittent is sometimes conjoined with dysentery. The 
best plan, here, is to neglect the former until the latter is re- 
duced. The same principle holds in the complication of dysen- 
tery with rheumatism, and some other diseases. But it is here 
supposed that the bowel affection is strictly inflammatory. In 
the low forms, the quinine might be adapted to both complaints. 



DIAREHffiA, ALYI FLUXUS. 



DEPINITIO N, — Any affection where the contents of the 
bowels, in a fluid or thin state, are too frequently discharged. 
This appellation is objectionable, as not expressing the patholo- 
gical condition. 

S Y M P T M S. 

If the case proceed from offensive ingesta, nausea or vomit- 
ing : surface cold and pallid, and pulse feeble. Sometimes 
approaches as a febrile affection, commencing with anorexia, 
foul tongue, chilliness and flushings, a quick, tense, irritated 
pulse, and dry skin. 

The bowels flatulent, rumbling; sometimes tormina and 
tenesmus, with a sense of weight and distension. 

The stools are thin and watery, or thick and tenacious, gluti- 
nous or jelly-like, consisting of slime or mucus, and of an 
ochreous, or clayish, or ashy, or slaty, or yellow, or green, or 
blue, or dark, or pale, or of a milky appearance, or purely 
bilious. When milky, falsely supposed to contain chyle, and 
hence the term Diarrhoea chylosa. The discharge of bile, not 
strictly diarrhoea. Or the discharges may be ingesta, fluid or 
solid, passed out unaltered, and then called Lientery. 



CAUSES. 

Irritating ingesta, cathartics urged to excess,, constipation, 
cold, heat, putrid exhalations, mental emotions, dentition. 



140 DISEASES OF THE ALIMENTARY SYSTEM. 

DIAGNOSIS. 

Resembles dysentery, and differs from it only in degree. 

PROGNOSIS. 

Favourable. When chronic it may run into dysentery. 

AUTOPSIC APPEARANCES. 

Slight phlogosis or congestion of the mucous membrane of 
the large intestines, or softening, or enlarged follicles ; or the 
membrane pale, relaxed, and flaccid. 

PATHOLOGY. 

Diarrhoea is a mitigated Dysentery. In diarrhoea there is 
more of irritation than inflammation. It is seated in the mucous 
coat. The irritation may be of the exhalant vessels, or of the 
mucous follicles, or both. When caused by cold, it is purely 
catarrhal, or consists in a transfer of function from the skin to 
the mucous membrane. The irritation extending to the liver, 
we have bilious discharges, or a suppression of bile. Lientery 
is referable to a high grade of irritability throughout the whole 
of the alimentary canal. 

The immediate seat of the affection is generally in the large 
intestines. 

TREATMENT. 

Caused by ingesta, an 
Emetic, followed by 

R h u b a r b, or M a g n e s i a, or Castor Oil. Should there be 
fever, 

Venesection, and a 

Mild Diaphoretic mixture, of which an 



DIARRHOEA, AL VI FLUX US. 141 

Opiate is the basis. If caused by a checked perspiration, 
reinstate the function of the skin, by a 

P e d i 1 u v i u m, or general Bath, followed by combinations of 
ipecacuanha and opium, e. g., 

Dover's Powder. Lientery is best managed by an 

Opiate, with astringents or absorbents, such as the creta- 
ceous preparations, in connexion with local bleedings and 
counter-irritation. The liver being implicated, a resort may 
be had to 

Mercury. 

DIE T, — Same rules as in dysentery. 



CHOLERA MORBUS. 



DERIVATION of this name, from x oX *h bile, and £sw, to flow, 
and morbus, disease, — meaning a bile flux. This name inap- 
plicable, as an excess of bile is rare, and the discharge is only a 
symptom. 

The disease recognised by ancient writers. Hippocrates 
alludes to it. 

SYMPTOMS. 

VIOLENT FORM, — Great variations in degree of violence. 
An attack usually comes on suddenly, or with little premonition. 
The earliest affections are soreness, and distension over the 
abdomen; fulness, tensive uneasiness, and oppression at the 
epigastrium, with borborygmi and twisting, colicky pain about 
the umbilicus — ejections of the contents of the stomach, mixed 
with a watery fluid or ropy mucus, and morbid secretions, of 
different hues, cramps and pain in the back. Discharges from 
the bowels, watery. Bile, rarely evacuated. 

During the intervals of vomiting, there are nausea, thirst, and 
wretchedness. As the case proceeds, the evacuations upwards 
and downwards recur more frequently, the cramp and spasms 
are exasperated, the trunk is rigid, fingers clenched, the ex- 
tremities distorted, constituting a tetanoid condition. In the 
interval of the paroxysms, exhaustion, confusion, noises in the 
ears, or deafness. 

The pulse throughout feeble, henceforward more so — increased 
depression of strength — cold, damp, collapsed surface — haggard 
countenance — burning in the stomach or at the umbilicus — de- 
sire for cold drinks — tongue moist, white, or milky — pukings 



CHOLERA MORBUS. 143 

and purgings more frequent and copious, of a fluid resembling 
greasy or dirty water, or like coffee-grounds, or the settlings of 
port wine — scanty or suppressed urination. 

Hereafter, there is a rapid sinking, approach to exhaustion — 
pulse tremulous, thready, hardly perceptible — extreme jactitation 
continues — muttering delirium — low, stammering, sepulchral 
voice — the skin cold — lividness of the countenance, fingers, and 
nails — impeded, anxious respiration, singultus, sunken eyes, hol- 
low cheeks, and purple or pallid shrivelled lips. (This account 
was written before Dr. Chapman had any knowledge of epidemic 
cholera.) 

MILDER AND MORE ORDINARY FORM. — Commences 
with sickness of stomach, flatulence, puking and purging of 
watery fluid, cold damp skin, weak pulse, cramp of the bowels, 
and sometimes of the extremities. 

Cholera is incident, chiefly, to close, sultry, autumnal weather ; 
occurring, however, sporadically, at all seasons, and in every 
climate. Endemic in our foggy, marshy districts, and portions 
of the India Peninsula. 

CAUSES. 

Paludal exhalations, putrid animal effluvia: — oftener traced to 
cold or moisture succeeding to heat or dryness, to exposure to 
the sun, to a draft of air, to dampness or coldness of the night, 
to sleeping with open windows, to wearing thin apparel, entering 
cellars, or to whatever checks perspiration. Also, excited by 
offensive ingesta, by crude, unripe fruits, or raw, or imperfectly 
cooked vegetables ; by tainted shell-fish, by a debauch in eating 
or drinking; by poisonous matters, as copper or arsenic; by 
harsh emetics or purgatives, or by fatigue. It is induced by 
passion, by grief or terror. 

Cholera prevails as an epidemic. It broke out in India in 
1817, and has since spread over Europe and this country, visit- 
ing, indeed, nearly the whole world. The true explanation of 
its origin is to be sought in an epidemic influence. 



144 fe DISEASES OF THE ALIMENTARY SYSTEM. 



DIAGNOSIS. 

Cholera may be distinguished from colic, by the absence of 
constipation ; from diarrhoea and dysentery, by more seventy 
of spasm, and by the evacuations being unmixed with bilious or 
bloody matters. 

PROGNOSIS. 

The issue is uncertain. 

FAVOURABLE SYMPTOM S,— Subsidence of cramps, and 
of the turbulent state of the alimentary canal ; bilious evacua- 
tions, rising of the pulse, restoration of temperature, genial mois- 
ture of the surface, undisturbed sleep. 

UNFAVOURABLE SYMPTO MS.— Extreme reduction of the 
pulse, prostration of strength, short, hurried respiration, cold- 
ness of the surface, clammy sweats, livid lips or fingers, tumid 
abdomen, watery, greasy, and dark flocculose discharges, sup- 
pression of urine, hiccup, haggard countenance, delirium. 

AUTOPSIC APPEARANCES. 

The stomach and bowels relaxed, flaccid, pale; the latter 
contracted, convoluted, or twisted, or vessels turgid, or phlo- 
gosis. Congestion of the liver, and of the other abdominal vis- 
cera. The lungs sometimes engorged, and also the brain. The 
head contains thick, viscid, black blood, and the blood drawn is 
of a similar appearance. 

PATHOLOGY. 

The primary irritation commences in the stomach, and, by 
sympathy, extends to other organs. In proof of this, the causes 
act primarily on the stomach, and the first ejections by vomiting 
consist merely of the contents of the stomach. Bile is not thrown 



CHOLERA MORBUS. I45 

up, before the biliary organs are secondarily affected. The liver 
being thus affected, it is stimulated to increased efforts, and we 
have the bilious discharges. But in a short time the energies 
of the stomach give way. The liver, sharing in this debility, is 
unable to return the blood which rushes into it, and engorgement 
and suppression of the hepatic secretion take place. These views 
are sustained by the history of the causes of the disease, its symp- 
toms, the phenomena on dissection, and the method of cure, and 
by the fact that the disease may be imitated by certain irrita- 
tions of the stomach. The change in the blood is secondary, 
and this change, as well as every other link in the series of 
events constituting the disease, is referable to the impressions 
on the stomach, and through it on the ganglionic nerves, and 
thence to the spinal marrow and brain. The state of the mucous 
surface of the digestive tube, varies in different cases and stages. 
At first merely irritation of the exhalants, though subsequently 
inflammation may ensue. 

TREATMENT. 

The indication is, the removal of the gastric irritation. To 
accomplish which, must first be removed, the irritating contents 
of the stomach — 

By an Emetic, — ipecacuanha, gr. xx., promoted by warm 
water, the stomach is tranquillized, spasm overcome, congestion 
removed, the balance in the circulation restored, and the system 
emerges from prostration. An emetic might be hazardous or 
inadmissible in extreme prostration, nor is it always demanded. 

No offensive matter existing in the stomach, the indication is 
to calm irritation, and subdue spasmodic pain and turbulence. 

Combinations with Opium, e. g., potash mixture with lauda- 
num, spirits of camphor, or camphor water, with nitrous acid, 
laudanum, and acetate of lead, and opium. Laudanum, opium, 
or old opium pill. Calomel, in doses of gr. viij. to gr. x., some- 
times. 

If the stomach reject all these, an anodyne enema, or the en- 
dermic use of morphia. 

i 10 



146 DISEASES OF THE ALIMEJNTARY SYSTEM. 

Clips or Lecchc s. — A sinapism over the epigastrium, and 
the latter to lower extremities. 

If heavy congestion exist, Venesection, guided by the pain 
and constitutional vigour, even if the pulse be very low, drawing 
blood slowly. In doubtful cases, topical bleeding from the abdo- 
men or spine, if pain in it, or spasm ; preceded by sinapism, 
warm, or vapour bath, hot fomentations and frictions. 

The disease soon may reach a stage requiring stimulants. 

1st. External. — Sinapism, blisters, dry heat, rubefacient 
frictions. 

2d. Internal remedies. — Liquor ammonias, solution of cam- 
phor in ether, spirits of turpentine, tinct. of capsicum, hot toddy, 
mint julep, and 

Opium, — When not forbidden by cerebral disturbance. 

To suspend the retchings and spasms, Tourniquets to the 
arm and thigh of opposite sides. 

Strapping the patient to a board in the horizontal position, 
said to suspend vomiting, and aid the retention of remedies. 

As soon as the stomach becomes retentive, Purges are 
usually required. 

Calomel in large doses, or castor oil or other laxatives, and 
afterwards, if the secretions be deficient, recur to calomel in 
small doses, alone or with opium. 

REGIME N. — No food ; drinks, cold lemonade, cold water, or 
ice. Chicken water as soon as the stomach will bear it. 



CHOLERA INFANTUM. 



This disease of children is perhaps peculiar to the United 
States. 

The period of its greatest prevalence is between the ages of 
twelve and eighteen months. It mostly begins among us in 
July, and continues till the accession of frost. It may, from its 
destructiveness, be called the scourge of children. 

Its popular name is the Summer Complaint. 

SYMPTO M S. 

It may approach like a dysentery, though sometimes its com- 
mencement more nearly resembles a cholera morbus. Its most 
common and characteristic presentation, however, is that of 
gastro-enteritis, in every gradation of violence, from simple 
irritation to the most intense phlogosis. Cerebral affection is 
sometimes early manifested in a tendency to delirium or stupor. 

The fever, when confirmed, is of an irregular remittent 
type. The desire for drinks is now unquenchable. 

The evacuations are watery, or slimy, or mucoid, or like 
coffee-grounds, or deep green, or of a colourless fluid, leaving a 
pink margin around the soiled portion of the napkin. They 
have usually a sour or putrid odour. Great irritability of the 
alimentary canal existing, the ingesta pass off immediately, as 
in lientery. 

When the attack runs a lengthened course, few diseases 
exhibit more emaciation, or greater alteration of condition and 
aspect. 

The alvine discharges sometimes, at this period, amount to 
forty or fifty in the twenty-four hours. 



|48 DISEASES OFTHE ALIMENTARY SYSTEM. 

Towards death, the face and belly may become bloated, the 
feet cedematous, and the mouth sprinkled with aphthae. The 
mental faculties and senses are apt to become extremely torpid. 

This protracted form of the disease may continue five or six 
weeks. 

CAUSES. 

Exclusively incident to children, and almost so to those living 
in cities. 

Damp, murky weather, is favourable to the origination of 
the disease. 

Exciting causes are improprieties in diet or clothing, teething, 
worms, and premature weaning. 

DIAGNOSIS. 

The affection may in general be easily recognised. Should 
it be confounded with diarrhoea, dysentery, or cholera morbus, 
it will probably, in such cases, be essentially the same with these 
diseases, and exact no difference of treatment. Even when 
mistaken for the common irritation of teething, the treatment is 
so analogous, that nicety of discrimination is not required. 

PROGNOSIS. 

A prognosis is very hazardous, since the most favourably 
looking cases are apt to terminate fatally, and vice versa. The 
chances, however, are vastly greater, other things being equal, 
when a free ventilation is commanded. 

The appearance of dark bilious or natural stools, is a most 
propitious sign. 

Among other unfavourable signs, too obvious in their cha- 
racter to be here mentioned, may be stated the purging of a 
pink-coloured fluid, or the fluid which leaves a pink stain 
around the soiled part of the napkin. This is an almost certain 
indication of death. 



CHOLERA INFANTUM. J49 



AUTOPSIC APPEARANCES. 

The brain in recent cases presents only slight venous con- 
gestion, or where cerebral excitement has existed, phlogosis of 
the membranes. But in protracted cases, effusions are often 
observable. 

In the alimentary canal, especially the upper part, we have 
the evidences of inflammation, and often contortion and intro- 
susceptions of the intestines. 

The peritoneum may exhibit a morbid appearance, and effu- 
sion in its cavity. The liver, in cases of long continuance, is in 
some instances so much hypertrophied, as to occupy two-thirds 
of the abdominal cavity. On the contrary, it has appeared atro- 
phied, and the spleen correspondency augmented. 

PATHOLOGY. 

The disease, in its most familiar presentation, is a gastro- 
enteric affection, soon involving the liver. The excitement of 
the stomach and intestines* being communicated to the liver, 
produces at first an increased flow of bile ; but the liver being 
long subjected to this high action, becomes exhausted, and its 
secretory power suspended. But in other cases, the inceptive 
impression is so strong, that the secretion of bile is at once 
arrested, and a lientery, perhaps, succeeds. The brain, and 
system in general, become soon involved in the play of sym- 
pathies. 

TREATMENT. 

1. The attack being of a dysenteric nature, 

Castor Oil and Laudanum are well adapted to its cure. 

2. But simulating cholera morbus, it is proper to begin 
with 

An Emetic; this will clear the stomach of its irritating con- 
tents, check vomiting, and create a tendency of blood and 
nervous excitement to the surface. 



150 DISEASES OF THE ALIMENTARY SYSTEM. 

The other treatment consists of the 
Warm Bath, 

Frictions and Sinapisms, and above all, 
Opiate Enemata. 

To quiet the stomach, when exceedingly irritated, may be- 
come a leading indication. 

3. We come now to the legitimate or ordinary form of the 
affection, which has been stated to be a gastro-enteritis. 

Best is it, when reaction is not complete, to resort to the 

Warm Bath, and a 

Sinapism over the Stomach. 

Febrile excitement, however, being developed, the measures 
are, 

V e n e s e c t i o n in some cases ; 

Leeching at the epigastrium may generally supersede vene- 
section. 

Cold Applications to the Scalp, leeching to the back of 
the neck, or behind the ears, and a moderate stimulation of the 
lower extremities, when there is a tendency to hydrocephalus. 

The continual purging which some practitioners employ in 
this and other bowel affections, is a great curse. Vitiated secre- 
tions are merely the effect of the intestinal irritation. 

Phlogosis having been reduced, and moderate evacuations 
having been premised, Dr. Chapman is accustomed to direct 

A Combination of Opium, Ipecacuanha, and 
Calomel, 

This prescription is as follows. 

R. — Calomel, gr. iij. 
Ipecac, gr. ij. 
Gum. Acac. xx. 
Pulv. Opii. gr. | 
M. et in pulv. vj. div. 

Of these, one powder may, on an average, be given every 
two hours. 

An occasional dose of the oleaginous mixture may be neces- 
sary for the removal of acrid colluvies. 

The Warm Bath. — To promote determination to the sur- 



CHOLERA INFANTUM. 151 

face, the head and belly being hot, and the feet cold, it will 
be better to employ a stimulating pediluvium, and apply cold to 
the heated parts. 

Blisters to the extremities fulfil the same indication. 

Should cholera infantum have passed by bad treatment into 
a diarrhoea, the cretaceous 'preparations and opiates become 
suitable. 

When the diarrhoea has become purely chronic and colli- 
quative, the astringents and tonics are indicated. But before 
making use of these remedies, we should be sure there is neither 
phlogosis of the intestines, nor congestion of the liver. The 
existence of the former demands the mildest anodynes, and 
that of the latter, mercury and opium. 

The discharges, however, being gleety and glairy, instead of 
serous, the balsams and terebinthinates should be preferred. 

Anodyne Enemata are as well suited to the mucous as the 
watery evacuations, and particularly when there are tormina 
and tenesmus. 

A flannel roller around the abdomen has been productive of 
signal utility. 

REGIME N. — In the early stage, when there is much gastric 
disturbance, milk is apt to form tough clots, and severely aggra- 
vate the inflammation. The mucilaginous drinks should there- 
fore be substituted. 

But when this acid condition of the stomach subsides, then 
nothing is so well adapted as human milk. At a later period, 
sago, tapioca, and other farinaceous articles may be preferable. 

Extreme debility supervening, a little ham may be allowed. 
But the best restorative is COUNTRY AI R,— Dr. Chapman 
gives the following rules for prevention : 

1. Never permit a child to be weaned within the year. 

2. Let the cold bath be daily used. 

3. Direct the use of flannel next .to the skin, and worsted 
stockings. 

4. Let the child be fed on milk with the farinaceous articles ; 



152 DISEASES OF THE ALIMENTARY SYSTEM. 

and after the sixth or eighth month, it may be accustomed to 
the use of weak broth without spice. 

5. During dentition, lance the gum whenever it begins to 
swell. 

6. Above all, let the child, when practicable, be removed to 
the country, early in the season, and there remain until the 
return of cool weather. 






COLIC A, OR COLIC. 



Of this affection, Dr. Chapman makes three divisions. — 1. 
Crapulent or Flatulent Colic. 2. Bilious Colic. 3. Saturnine 
Colic. 

FLATULENT COLIC. 

Much of what is said of this form, equally applies to the two 
others. 

SYMPTOMS. 

Sickness of stomach; spasmodic pains; flatulent distension, 
borborygmi, twisting around the navel, and occasionally 
cramps of the abdominal muscles, and of those of the low r er 
extremities, and unrelenting constipation. The vomiting is 
sometimes violent, the substance discharged may finally be 
stercoraceous. The pulse, at first little changed, soon becomes 
feeble and diminutive, and the surface cold. Should inflamma- 
tion occur, the pulse is hard and corded, the temperature of the 
body very unequal, and the abdomen tender. 

If relief be not afforded, this state is succeeded by a return 
of the diminutive pulse, cold damp skin, abatement, or cessation 
of the pain, a haggard countenance, singultus, and the other 
signs of approaching dissolution. 

CAUSES. 

Indigestible articles of food ; the vinous or alcoholic liquors ; 
collections of indurated fseces. 



154 DISEASES OF THE ALIMENTARY SYSTEM. 

Exposure to cold, and particularly when followed by a meal 
during the chill. Sympathy with distant parts. Lesions of the 
spinal marrow. 

The stomach and intestines sometimes acquire an extraordi- 
nary irritability. 

DIAGNOSIS. 

To distinguish the stercoraceous vomiting proceeding from 
an introsusception of the intestine, from that proceeding from 
an inverted peristaltic action without an introsusception, is im- 
possible. 

Cc4ic is diagnosticated from enteritis by the paroxysmal and 
spasmodic nature of the pain, the relief at first afforded on pres- 
sure, and by the flatulence and correspondent intumescence. 

But to hernia, it is very analogous, both in the early and late 
stages. In doubtful cases, an examination should always be 
made. 

PROGNOSIS. 

Colic is for the most part easily managed. The ejection of 
stercoraceous matter is an almost fatal sign. 

AUTOPSIC APPEARANCES. 

The intestine distended with flatus, ingesta, or faeces. It is 
sometimes alternately contracted and dilated, exhibiting a series 
of pouches. 

The case being of long continuance, with manifestation of 
spasm, we meet with the marks of phlogosis, and occasionally 
with- introsusceptions. The last are sometimes accompanied 
with gangrene, though more generally by no lesion whatever. 
Many of them are probably formed at the point of death. They 
occur chiefly in the ileum. The upper is mostly received into 
the lower portion. Knots in the intestine are also sometimes 
formed. 

The stomach occasionally participates in the spasm, and it, 



FLATULENT COLIC. 



155 



together with the parietal peritoneum and liver, may be found 
in a state of phlogosis. 

PATHOLOGY. 

The disease may be seated in any portion of the alimentary 
canal; though its principal location is about the ileo-ccecal 
valve. 

Commencing in simple spasm of the muscular coat, it inva- 
riably terminates, if long continued, in phlogosis. This may be 
confined to the muscular tissue, or it may involve the others. 

The pain has been generally attributed to spasm, but more 
correctly to the flatulent distension. 

The immense formations of gas, are ascribable in some in- 
stances to the decomposition of the intestinal contents, and in 
others, to its secretion by the mucous membrane. 

TREATMENT. 

The colic arising from offensive matter in the stomach, it 
should be removed by an Emetic, An attempt should next be 
made to subdue pain and calm irritation by the cordial, carmi- 
native, and anodyne preparations, such as ether, Hoffman's 
anodyne liquor, ginger tea, the essential oils, &c. The same 
effect is sometimes gained by large draughts of tepid water, or 
still better, of very hot water, and, in particular cases, of very 
cold water. 

Colic dependent on constipation, demands, of course, the 
Purgatives, the best of which is an ounce of castor oil, com- 
bined with a drachm of the oil of turpentine. It may happen 
that this state is owing to accumulations of indurated faoces in 
the rectum, to be removed by scooping them out. 

Colic caused by cold only, may be cured by an opiate dia- 
phoretic, without premising any evacuation. This should be 
conjoined with warmth applied to the surface. For the expul- 
sion of flatus, the terebinthinate, or assafoetida enemata are 
excellent. A long bougie introduced into the intestine some- 
times answers a very good purpose. 



156 DISEASES OF THE ALIMENTARY SYSTEM. 

For introsusception, when it can be diagnosticated, which it 
never can be with any certainty, the best measure, probably, is 
a large anodyne enema. This is certainly the most appropriate 
treatment of stercoraceous vomiting, when not connected with 
an invagination. 

On the occurrence of phlogosis, every stimulating remedy 
must be forborne, and the lancet resorted to. Next we may 
employ topical bleeding, and ultimately a blister. 






BILIOUS COLIC, 



SYMPTOMS. 



The attack is occasionally preceded by the evidences of 
hepatic derangement. At other times, it comes on with a chill, 
followed by a fever, attended with more or less perturbation of 
the alimentary canal, characteristic of colic. But it is as fre- 
quently introduced by violent vomitings. Bile is rarely thrown 
up in the commencement ; is thrown up very copiously after a 
time, and ceases at a still more advanced period, owing to a 
torpor of the liver from over-excitement. The retching, how- 
ever, still continues. 

Whatever may have been the mode of commencement, the 
pulse gradually rises till it acquires much force and volume. 
Sometimes, when the aggression is very violent, no reaction 
takes place, and the collapse may be as complete as that in 
malignant cholera. 

Excruciating pain about the umbilicus ; acute or dull pain 
in the head, and often depravation of vision ; mind occasionally 
affected, and at times nervous tremors, or paralysis of the upper 
extremities. 

CAUSES. 

The causes of autumnal fever; irritating ingesta ; and epi- 
demic influence. 



DIAGNOSIS. 

Distinguish from other colic, principally by the biliary de- 
rangement, and the fulness and activity of pulse. 



158 DISEASES OF THE ALIMENTARY SYSTEM. 



PROGNOSIS. 

Pretty much like that of flatulent colic. Very favourable is 
the reappearance of bile after its suppression ; and most unfa- 
vourable, of course, is a want of reaction. 

AUTOPSIC APPEARANCES. 

Much like those of flatulent colic. The Jiver is disordered, 
particularly by congestion. The stomach and intestines are 
more affected by inflammation than in the other variety. 

PATHOLOGY. 

The chief point of dispute, is whether the liver is preter- 
naturally excited, or depressed into torpor. There is, however, 
every reason to believe that in the advanced stage it becomes 
torpid. 

The nervous and cerebral disturbance may be either original 
or secondary. 

TREATMENT. 

As a febrile affection, attended with intestinal spasm, or 
phlogosis, and hepatic, and other congestions, 

Venesection is demanded, and should in violent cases pre- 
cede all other remedies. 

Topical Bleeding and Fomentations, or Counter- 
irritants, to the epigastrium. Not quieting the stomach by 
these means, and especially if we have reason to attribute the 
nausea to irritating contents, we should direct 

An Emetic. 

An Old Opium Pill, or an OpiateEnemat a. 

The Warm Bath. — As soon as the stomach will bear a pur- 
gative, this should be given. But not succeeding in our attempt 
to open the bowels, we may, if there be force in the pulse, or 
any intensity of pain, repeat venesection. Topical bleeding 



BILIOUS COLIC. 159 

may be also applied to the abdomen, though, at this juncture, it 
may do much greater service if applied to the spine. 

Still not succeeding in procuring a stool, we resort to 

Purgative Injections, — Senna tea, with a drachm of 
jalap in it, is very good in this case. Tobacco enemata are 
here justly esteemed. Distending the bowels with tepid water 
is a further expedient. It should be recollected that the mildest 
enemata, by relaxing spasm, will prove effectual, when the most 
active, and particularly those of a harsh nature, are unavailing 
or aggravatory. 

In regard to purgatives, it may here be mentioned, that the 
lenient articles are usually most suitable. The drastics often 
render the spasm still more violent. Castor oil, or Epsom salts, 
alone or combined with magnesia, are valuable ; but senna tea 
is on the whole to be preferred. A great favourite with Dr. 
Chapman, is a combination of a grain of opium with five of 
calomel, repeated every two or three hours. 

A Blister may be applied to the abdomen, or, in the event 
of spinal irritation, to the spine. 

The case having been thus prepared, nothing is so valuable 
as the 

Mercurial Impression.— It is well calculated to over- 
come obstinate constipation, and to prevent disorganizations. 



COLICA PICTONUM, OR PAINTERS' COLIC, 
DEVONSHIRE COLIC, ETC. 

Its popular titles with us are lead colic and dry belly-ache, 
SYMPTOMS. 

Coming on gradually, nothing may at first be complained of, 
except a general feeling of wretchedness, uneasiness in the epigas- 
trium, and right hypochondrium, indigestion, and constipation. 

Or, without this premonition, the disease may at once com- 
mence with pain at the pit of the stomach, descending to the 
intestines, a. twisting sensation around the navel, nausea, obsti- 
nate constipation, and frequent ihough ineffectual desire to go 
to stool. 

The pains soon increase in violence, and the abdomen be- 
comes exquisitely tender. The muscles of the abdomen and 
the lower limbs contract in hard knots, and there is incessant 
vomiting. 

Some cases much resemble dysentery. 

In most instances, paralytic affections supervene. 

It scarcely ever lasts less than five days, and may endure 
months. 

When the disease becomes decidedly chronic, the nutritive 
process is greatly vitiated, emaciation ensues, the countenance 
is sallow or leaden, the secretions are diminished, and the mind 
is very irritable, or imbecile ; and thus the affection proceeds, 
until usually it settles down into invincible palsy of the inferior, 
though oftener of the upper extremities. 

It may also terminate in mania, epilepsy, loss of some of the 
senses, or dropsy. 



COLICA FICTONUM. iq\ 



CAUSES. 



The internal use of the preparations of lead, or an external 
exposure to them. Thus, persons have contracted the disease, 
from eating things which had been contained in a leaden or 
glazed jar, from drinking liquors impregnated with some satur- 
nine preparation, possibly, in some instances, from drinking 
water which had been conducted through leaden pipes, from 
living in the vicinity of lead-works, or even from living in rooms 
recently painted. 

It is ascertained that the carbonic acid commonly contained 
in water, will act upon the pure metal. 

Dr. Chapman has never seen the colic result from the use of 
the acetate. 

The affection has been ascribed to some other metals, and also 
the causes already detailed as productive of the other kinds of 
colic. But it is probable that in the instances in which this 
reference was made, there was either some unthought of expo- 
sure to lead, or the disease was really bilious colic. 

DIAGNOSIS. 

Distinguish from bilious colic by the unexcited condition of 
the pulse, the absence of very marked biliary disorder, the ten- 
dency to paralysis, and the mode of origin. 

PROGNOSIS. 

The cure is difficult and slow, even in the most recent and the 
mildest cases ; but old and complicated ones may be deemed 
desperate. 

AUTOPSIC APPEARANCES. 

The reports of morbid anatomists on this subject are very 
inconsistent. Paris, Roche, and Sansom declare that they found 
the intestines contracted at several points, with a hard dry mat- 

11 



162 DISEASES OF THE ALIMENTARY SYSTEM. 

ter in the intervals, and the mucous membrane reddened, thick- 
ened, and ulcerated. 



PATHOLOGY. 

Rather uncertain. The best opinion at present seems to be 
that the disease is a modified neuralgia, particularly of the 
spinal and sympathetic nerves, the irritation of which, when 
intense and enduring, sometimes leads to inflammation. 

TREATMENT. 

Taken in the inchoative stage, it may be sometimes arrested 
by purgatives and a subsequent use of opiates. 

But the disease being formed, more decided measures are 
necessary. 

The indications and remedies do not differ much from those 
of bilious colic. 

Notwithstanding the state of the pulse, unless it be extremely 
depressed, Dr. Chapman resorts first to 

Venesection, and afterwards to 

Local Bleeding and Blisters along the spine. 

Calomel and Opium may then be used as a purgative. 
Their action may be assisted by all the means pointed out in 
the treatment of bilious colic. For relaxing spasm, we may 
resort to the warm bath, fomentations, the tobacco cataplasm, 
or tobacco fumes introduced into the abdomen. 

Purgation having been effected, the remaining treatment 
consists of opiates, laxatives, and mercury. The last, used in 
doses suited to produce the constitutional impression, is the 
most effectual means of eradicating the disease, and its sequelae, 
— paralysis, &c. 

PROPHYLAXIS. 

The effluvia from the saturnine preparations should never be 
suffered to come in contact with an empty stomach. Dr. 
Chapman has been assured by one of our most extensive manu- 



COLICA PICTONUM. 1(53 

facturers of white lead, that even a spoonful of oil, taken occa- 
sionally, with this view, is very efficacious. 

An occasional draught of diluted sulphuric acid, prepared in 
the form of lemonade, will make a sulphate of lead, which is 
insoluble and inert. 

The hands of a workman should be washed, and his clothes 
changed, after work. 

As an antidote to any of the saturnine articles received into 
the stomach, the sulphate of magnesia or of soda, is the best, 



ACUTE PERITONITIS. 

This treatise will chiefly regard parietal peritonitis. 

SYMPTOMS. 

Being introduced by languor, chilliness, and rigors, aches in 
the back and inferior extremities, the disease is developed by 
the supervention of fever, oppression of the epigastrium, more 
or less acuteness of pain in the lower part of the belly, some- 
times circumscribed, though it may be diffused. The pain in 
the beginning is apt to fluctuate, and may be thus characterized 
throughout the case ; but it is more apt to become fixed. The 
covering of the bladder being concerned, there will be difficulty 
of urination ; of the diaphragm, straightness, often spasmodic 
uneasiness, and, uniformly, singultus; of the stomach, nausea 
and vomiting ; and of the intestines, constipation, &c. 

Sometimes, thirst, internal heat, and dryness of the fauces ; 
pulse small, quick, and corded. 

In the course of twenty-four hours, the sensibility is so great, 
that the weight of the bed-clothes can scarcely be borne. The 
pulse becomes upwards of one hundred in a minute, the tongue 
loaded with a white fur, or clean with polished tip and edges, 
and the countenance assumes the aspect of distress. 

The symptoms progressing in violence, the abdomen may 
become greatly swollen, from flatulence of the bowels, or em- 
physema of the subcellular tissue. 

At this time, it is not rare for the pain suddenly to cease. 
Simultaneously, the pulse sinks in force, while it vastly in- 
creases in rapidity. There are vomitings of dark blood, sin- 
gultus, and collapse. In children, a sudden translation may 
take place to the brain, productive of convulsions. 



ACUTE PERITONITIS. 1(55 

Like gastritis, this phlegmasia may exist in a state of disguise. 
DURATION. — Peritonitis may run its course in five or six 
days, or even half that period. 

CAUSES. 

No age is exempt, though that of maturity is most suscep- 
tible of the disease. 

Various applications of cold, mechanical violence, extrava- 
sations into the peritoneal cavity, the sudden suppression of 
customary discharges, parturition, recession of rheumatism, 
gout or cutaneous eruptions, and epidemic influence, are among 
the causes. 

DIAGNOSIS. 

Distinguish from gastritis, enteritis, and colic. Very charac- 
teristic of peritonitis is the tenderness and early tensiveness of 
the belly, rare inclination to go to stool, and the little mitigation 
of pain experienced from alvine discharges. The patient lies on 
his back, with the legs drawn up, in order to throw the weight 
of the intestines on the spine, and relax the abdominal muscles. 

It is discriminated from neuralgia of the abdominal muscles 
or peritoneum, by the absence of constitutional disturbance. 

PROGNOSIS. 

The case being established, proves, for the most part, exceed- 
ingly intractable. Being the result of injuries, or extravasated 
fluids, except in the case of dropsy, the prognosis is most unfa- 
vourable. The sudden cessation of pain, in the height of the 
disease, is the precursor of gangrene and death. 

AUTOPSIC APPEARANCES. 

Vascularity, or lividness, in patches, or diffused ; adhesions 
to the viscera; frequent extensions of inflammation to the tegu- 
mentary peritoneum, and the subjacent tissues ; extravasations 



166 DISEASES OF THE ALIMEJNTARY SYSTEM. 

of coagulable lymph, serum, blood, or pus ; and gangrene, but 
never ulceration. The blood may be withdrawn from the peri- 
toneum, so as to leave it pallid, in the act of death. 

TREATMENT. 

Copious Venesection, — Except when reaction is imper- 
fect. We should not be intimidated by the weakness of the 
pulse, or the appearance of general debility, since these will be 
obviated by the blood-letting. 

h 6 6 eh in g. — To the detraction of from six to ten ounces. 

Warm Fomentations, — But when the inflammation is in- 
tense and the skin hot, and the general vascular action high, 
cold applications may suit better. 

Blister s. — When the phlogosis has been decidedly reduced 
by the previous means. 

Purges of castor oil ; or, where the irritation is moderate, 
castor oil in union with the oil of turpentine. They should not 
be employed until the inflammation has been somewhat con- 
trolled by blood-letting. The bowels having been well evacu- 
ated, it will be sufficient to keep them soluble with emollient 
enemata. 

The foregoing measures proving inadequate, we are next to 
direct — 

Diaphoretic s. — These determine the blood to the surface, 
and change the state of the capillaries. The Dover's Powder, 
aided by the Vapour Bath, answers best. This is the time for 
the introduction of opium, which should henceforward enter into 
combination with every remedial measure. 

Not succeeding with the above, we may resort to the 

Calomel, Opium, and Ipecacuanha, — Mercurial fric- 
tions may be used ; or the raw surface of the blister may be 
dressed with the ointment. 

We approach the period, in which the vital forces fail, and a 
tendency to gangrene supervenes. 

Carbonate of Ammonia, or, still better, Oil of Tur- 
pentine. 



ACUTE PERITONITIS. 1(J7 

The latter may be also employed in the form of enema, to 
obviate the flatulence. 

Wine. 

The case wearing the typhoid aspect from the commence- 
ment, general bleeding should be more limited, and an earlier 
resort should be had to blisters, diaphoretics, and mercury. 



CHRONIC OR SUBACUTE PERITONITIS, 



SYMPTOMS. 

May be either a degeneration of the acute disease, or primary. 
Being the latter, its approach may comprehend weeks, or 
months, without exciting suspicion. 

A tightness, or pinching soreness, from one ilium to the other, 
though the skin and abdominal muscles are loose. The tight- 
ness relieved by evacuations from the bowels, and much in- 
creased by constipation. Pain felt on coughing, or sneezing. 
Torpor of the bowels, commonly, — the stools indicating a want 
of bile ; the urinary secretion deficient and vitiated ; digestion 
depraved, and the appetite impaired ; pulse nearly natural, or 
exceedingly accelerated ; tongue more or less furred in the 
morning ; thirst urgent, though there is no apparent fever, or 
even heat of surface ; face pale, or sallow and languid ; some- 
times cough ; and towards evening oedema of the feet and 
ankles. 

The case being exacerbated, is developed by greater pain, 
tension, gastric disorder, constipation alternating with diarrhoea, 
slight fever, aggravated in the evening, and a cleaner or florid 
tongue. 

Those tissues which in even slight acute attacks display the 
sharpest pain, may suffer the greatest disorganizations by a 
gradual process, without any manifestation whatever. 

The disease progressing, involves the constitution in hectic, 
and a general cachexia. The cutaneous vessels may become 
remarkably turgid. Diarrhoea is usual in the advanced stages. 
Whether there be ascites or not, anasarca of the lower ex- 
tremities almost always takes place. 

May endure from a few weeks, to a space of years. 






CHRONIC PERITONITIS. \QQ 



CAUSES. 

The acute affection, ill-cured ; the causes of acute peritonitis 
acting on an old or impaired constitution, or one cold and 
phlegmatic; habitual drunkenness; protracted intermittents. 

DIAGNOSIS. 

Much like that of the acute disease. Distinguish also from 
colitis. 

PROGNOSIS. 

Usually curable, when no structural lesions have taken place. 

AUTOPSIC APPEARANCES. 

Besides those incident to acute peritonitis, we may observe 
thickening, or a granulated, tuberculated, or ulcerated surface, 
adherent hydatids, the intestines agglutinated in masses, disor- 
ganization of other viscera, and serum effused in so great an 
amount as to constitute ascites. 

TREATMENT. 

We should at first endeavour to reduce the inflammation by 
the means detailed under the preceding head, tempered to the 
condition of the system. Much has been said of the value of 
mercurial inunctions; which on a proper reduction of phlogosis, 
should be, perhaps, resorted to. 

Subsequently, the disease continuing, we may maintain a 
strictly regulated regimen, and direct calomel, ipecacuanha, 
and opium, — the last to be freely used in case of much pain. 
But mostly, these instances are probably incurable. Dropsy 
coming on, diuretics may be combined. 



DISEASES OF THE RESPIRATORY 
SYSTEM. 



Dr. Chapman begins with the affections of the mucous tissue, 
and, as most simple, he first takes 

CATARRHUS OR CATARRH. 

ACUTE FORM. 

The etymological meaning is, a defluxion. 

It consists in a phlogistic irritation of the mucous membrane 
of the bronchi, larynx, trachea, fauces, nose, and frontal 
sinuses ; or it may involve only a part of these structures. 

This irritation being sometimes unaccompanied with a de- 
fluxion, is called by Dr. Chapman, according to custom, 
bronchitis. It is the same which some, by a great solecism, 
call the dry catarrh. 

SYMPTOMS. 

The violence may vary exceedingly. 

INTRODUCTORY.— A sense of fulness about the head; 
sneezing ; a distillation of an acrid fluid from the nose and 
eyes, technically called coryza, — lassitude, muscular pains, — and, 
finally, rigors, or, at least, increased sensibility to cold. 

MORE ADVANCE D,— Hoarseness, titillation of the throat ; 
stricture of the chest ; embarrassed respiration ; a dry, irritating 
cough, or accompanied with glairy mucus raised by hawking ; 



CATARRHUS OR CATARRH. 171 

and fever, usually exacerbated in the evening, and associated 
with acute pain about the frontal sinuses. 

AFTER A FEW DAYS, in favourable cases, the affection 
passes oft' with copious and easy expectoration of yellow mucus, 
or by a watery diarrhoea. But it may run into a chronic dege- 
neration. 

In weakly, phlegmatic constitutions, a state of collapse ensues, 
attended with wheezing and rattling from bronchial accumula- 
tions. Owing to this obstruction, the blood being no longer 
decarbonized, there take place lividity of countenance and 
often death. But in some instances, particularly when epi- 
demic, the disease is formidable from the beginning. This 
exacerbated condition may arise from the complication of some 
other pulmonary, or a gastric, hepatic, or cerebral inflammation. 

CAUSES, 

Sudden vicissitudes of weather ; inadequate clothing ; drafts 
of air, particularly when the body is heated ; damp clothes : 
sleeping in damp sheets, or in a damp room ; standing on wet 
ground ; entering suddenly a cold cellar or such other place ; 
certain effluvia, as from fresh paint, or particular flowers ; the 
irrespirable gases; the inordinate use of snuff; and an epidemic 
influence. 

Proceeding from the last cause, it is called Influenza. This 
epidemic has existed at least from the fourteenth century. Its 
general direction is from north to south. The susceptibility to 
the disease is destroyed for the time by one attack, though, on 
a return of the epidemic, it may be revived. It does not, how- 
ever, secure an individual from a catarrh, contracted in the 
ordinary manner. 

DIAGNOSIS. 

The secretion being abundant, the rattle revealed by the 
stethoscope is loud and gurgling, though occasionally sibilous; 
being deficient, the tone is still more sonorous, resembling the 
cooing of a pigeon, or the scrape of a large violoncello, denoting 



172 DISEASES OF THE RESPIRATORY SYSTEM. 

a tumidity of the lining membrane from inflammation. Con- 
nected, also, with large secretions, is a suppression of the re- 
spiratory murmur, which may, however, be suddenly restored, 
from a removal of the obstruction by coughing. 

PROGNOSIS. 

The epidemic form most dangerous, and sometimes very 
fatal. Either an exuberance of secretion, augmenting oppres- 
sion, or a total want of it, denoting high inflammation, is unfa- 
vourable. Thin and glairy sputa denote a continuance of irri- 
tation ; while thick yellow sputa indicate the approach of 
convalescence. Catarrh, however, from the danger of its com- 
plications, or degenerations, should never be neglected. 

AUTOPSIC APPEARANCES. 

The membrane is found covered with the matter of sputa ; 
which being wiped away, there is disclosed a redness, prevailing 
mostly about the end of the trachea, and in the bronchi of the 
upper lobe of one lung. In non-secreting cases, the membrane 
is also tumefied. But widely spread complications are generally 
associated with the fatal instances. 

PATHOLOGY. 

The affection commences in irritation ; which, should the 
case become at all severe, is converted into inflammation. Its 
first attack is commonly in the pituitary membrane of the nose, 
reaching sometimes to the frontal sinuses, which is vulgarly 
called a cold in the head. It afterwards descends the trachea 
and bronchii. The alimentary canal, brain, &c, may also be 
implicated. 

TREATMENT. 

1. FOR THE FORMING STAGE. 

An p i a t e. — Nothing answers so well to suppress an attack. 



CATAKRHUS, OK CATARRH. 173 

On the same principle, operate spirituous liquors, exercise, and 
other diffusible stimulants. 

An opiate being for any reason precluded, resort may be had 
to a hot pedihimum, sweet spirits of nitre, antimonial wine, ace- 
tate of ammonia, or other mild diaphoretics, assisted by warm 
diluents. Or a warm infusion of the Eupatorium perfoliatum, 
may be preferable. A copious draught of cold water is occa- 
sionally still more effectual. The determination to the head 
being considerable, the pediluvium may be made more stimu- 
lating by the addition of mustard and salt. 

The pain in the frontal sinuses being very severe, leeches, 
vesication, and the snuffing up of various vapours, or a dose of 
opium and calomel 

2. THE CATARRH BEIM FULLY FORMED, 

Venesection. — When the case is violent. The repetition 
should be regulated by the pulse and other considerations. 

Local Bleeding, 

Purging with Salines, The attack being violent, or at- 
tended with much oppression, Calomel answers better. 

Nitre, and Tartar Emetic— Exhibited early, an emetic 
is strikingly useful, and is well calculated to relieve oppression* 
But it is too unpleasant to be generally used. The tartar 
emetic, however, in small doses, and the nitre may be used 
when there is no phlogosis of the alimentary canal. When 
there is, we may substitute the N e u t r al M i xt u r e. 

Blisters, — To be used when the inflammation is reduced, 
there yet remaining a hard lingering cough, and a remnant of 
pain in the chest. Applied too soon, they do more harm than 
good. 

Calomel, Opium, and I pc c a c u a n h a. — Applicable in the 
same stage with blisters. 

About this time, the state of fearful depression and excessive 
secretion, is apt to supervene. Dr. Chapman considers it more 
fully in the treatment of Bronchitis, here only remarking that it 
is chiefly to be met with C arbon ate of Ammonia, aided by 
Cordial drinks. 

The acute stage of catarrh being fully subdued, Cough Mil- 



174 DISEASES OF THE RESPIRATORY SYSTEM. 

tures, as they are called, become serviceable. They nearly 
all contain Opium, 

As a means of promoting expectoration, and calming the irri- 
tation which excites coughing, Dr. Chapman recommends the 
following compounds: — 

R. — Extract. Glycyrrh. 3iij. 
Aq. ferv. f 3iv. 

M. Ft. solut. et adde. 
Sp. Mth. Nitr. f 3ij. 
Vin. Antimon. 3j. 
Tinct. Opii, gtts. xl. 

R. — Carbonate of Potash (or Soda), 3j. 
Antimon. Wine, f 3j. 
Tinct. of Opium, gtts. xl. 
Compound Spirits of Lavender, f3ij. 
Pure Water, 3iv. 
Mix. 

Of these preparations, may be taken half a tablespoonful every 
two hours. 

It is well ascertained that the Alkalies possess an effectual 
control over this state of the mucous membrane. 

As a palliative, a solution of 

Sugar, with enough lemon-juice or vinegar to acidulate it, 
simmered slowly into a syrup, will prove useful. 

REGIME N. — The diet should consist of the demulcents. 
Should something more be necessary, gruel, potatoes, the 
vegetable soup, &c, may be employed. 

Confinement in a room, with the temperature duly regulated, 
should be observed, and in severe cases, the patient ought to 
maintain his bed. 

Sometimes a lingering cough is left, which resembles per- 
tussis. It will be commonly found that this is owing to diffused 
phlogosis, or relaxation about the fauces. 



CATARRHUS yESTIVUS, OR HAY FEVER. 175 



CATARRHUS .ESTIVUS, OR HAY FEVER. 

This disease, which prevails about the time hay grass blooms — 
that is, in the early part of spring — was formerly thought pecu- 
liar to England. But Dr. Chapman has seen it in this city. 

Attacking first the external apparatus of the eye, it thence 
extends to the Schneiderian membrane, and the other parts liable 
to the incursions of common catarrh. It is accompanied with 
nervous irritation, rather than fever. Sometimes it is marked 
by paroxysms, like those of spasmodic asthma. Enduring for a 
month or six weeks, it subsides, to revert next season, which it 
may do for many years, in spite of precautions. 

The cause of the affection is doubtful. 



CHRONIC CATARRH. 



The affection which Dr. Chapman considers under this name, 
is that form which ultimately degenerates into what has been 

Called CATARRHAL CONSUMPTION. 

SYMPTOMS. 

Cough ; pain in the chest ; soreness of the throat ; sputa of 
a glairy phlegm, in the midst of which are small masses like 
boiled rice, mistaken often for pulmonary tubercle. Being 
sebaceous, however, they melt on subjection to heat, while 
tubercular matter does not. The expectoration gradually be- 
comes more copious, mucoid, puriloid, and finally pus ; which, 
however, is secreted by the mucous membrane. The purulent 
matter is grayish or greenish, and occasionally tinged with 
blood. It may be deficient, or may amount to even pints in 
twenty-four hours. The pulse hard and accelerated, and the 
system ultimately hectic. The disease invading other structures, 
may assume the form of some other pulmonary disease. 

CAUSES. 

May succeed the acute affection, or arise from the same 
causes. It is owing more frequently to the inhalation of par- 
ticles thrown off in certain mechanical operations. Dr. Chap- 
man ascribes it also to disorder of the digestive aparatus, or 
uterus, to rheumatism, gout, or the repercussion of eruptions. 



CHRONIC CATARRH. 177 



DIAGNOSIS. 

Often difficult from the complications of the disease. Dis- 
tinguish from tubercular consumption, by the fluid nature of the 
sputa. Proceeding from a tubercular cavity, they are thick, 
woolly, and always spit up in dabs, or separate masses. This 
observation was first made by Dr. Chapman. Tubercle is 
sometimes, however, productive of a catarrh. 

Learning from percussion the presence, or absence, of tubercle, 
we perceive, if the attack be chronic catarrh, the same sounds 
as in the acute affection. We have, also, as guides, the absence 
of pectoriloquism, cavernous respiration, the permanent want 
of the respiratory sound from induration, &c, — sounds which 
denote phthisis. 

AUTOPSIC APPEARANCES. 

In an early stage like those of acute catarrh. In older cases 
is exhibited hardening, or softening; where the affection is 
excited by acrid inhalations, small ulcers; dilatation of the 
bronchi, and sometimes merely a preternatural paleness of the 
membrane. Besides, we occasionally observe extraneous com- 
plications. 

TREATMENT. 

Concerning this subject, Dr. Chapman is brief; since both 
the indications and the remedies are much like those of phthisis. 
Depletory methods, however, may in most cases be used more 
freely. 

Venesection, Local Bleeding, Blistering. 

Ipecacuanha, Tartar Emetic, Nitre, or such other 
sedative articles, and a L w Diet, 

An Emetic may next be resorted to occasionally, with great 
efficiency ; as may also the 

Cough Mixtures formerly mentioned, which, together 
with the 

12 



178 DISEASES OF THE RESPIRATORY SYSTEM. 

Fixed Alkalies, may be entirely substituted for the 

emetics. 

This course failing, have recourse to the alterative effect of 
Calomel, in combination with Opium and Ipecacuanha. 

This also failing, we may try the 
Balsamic Medicines, of which, Dr. Chapman prefers the 
T o 1 u. — To the same description of cases, rather more 

reduced, are adapted the 
Terebinthinate s, — We may try tar water, or inhalations 

of tar. Other remedies are preparations of Iodine and 

Chlorine, 



BRONCHITIS ACUTA, OR ACUTE 
BRONCHITIS. 



This affection was formerly called Peripneumonia Notha, 
or Catarrhus Suffocativus, vel Nothus. The term Bron- 
chitis, is better, though objectionable from its implying inflam- 
mation, which is not the real pathological condition. 

SYMPTOMS. 

The mode of aggression is diversified. It may commence 
like ordinary catarrh, or suddenly, with heavy pulmonary op- 
pression, and wheezing, and rattling from excessive secretion. 
Tension, but seldom acute pain, in the chest ; cough insignifi- 
cant and dry, though phlegm is sometimes sparingly expecto- 
rated. No hoarseness, nor defluxions from the nose or eyes ; 
the pulse rather accelerated, or slower, fuller, and more com- 
pressible than natural ; the skin cold ; face pale, and hebetude 
and confusion of mind. 

Differing from this, we may have complete reaction, as 
shown by high fever and headache. Here too, however, we 
have the distressing tightness of chest, but no positive pain, and 
a cough, without much expectoration. 

MORE ADVANCED SY MP T MS.— Increased oppression, 
cerebral heaviness, or low delirium, livid countenance, and the 
various evidences of an adynamic state. The bronchial secre- 
tion is, at this period, usually enormous, thin and pituitary, with 
loud wheezing and rattling. 



180 DISEASES OF THE RESPIRATORY SYSTEM. 

Death ensues from suffocation, consequent on excessive ac- 
cumulations in the bronchi, from absolute exhaustion, or from 
cerebral disturbance. 

But the disease may be so mild as scarcely to attract atten- 
tion, and it may be complicated with various pulmonary affec- 
tions as well as with those of the alimentary canal. 

CAUSES. 

Same as those of catarrh. 

DIAGNOSIS. 

The pathognomonic symptoms are wheezing and rattling. If 
we should be embarrassed by complications, a recourse to the 
stethoscope, which reveals the same sounds as in catarrh, will 
dissipate the obscurity. 

PROGNOSIS. 

A dangerous disease. 

FAVOURABLE SIGN S.— Easy expectoration of thick, yellow, 
tenacious matter, improved respiration ; warm skin, and above 
all, defluxions from the nose. 

It terminates in three or four days, or may do so even within 
a few hours. 

AUTOPSIC APPEARANCES. 

The bronchi will be found gorged with glairy secretions; 
and the vessels sometimes injected. Yet the mucous membrane 
is usually rather paler than natural. The lungs, brain, and 
other structures may be also involved. 

PATHOLOGY. 

Differs from catarrh, in proceeding from irritation and con- 
gestion, instead of inflammation of the mucous membrane, and 



ACUTE BRONCHITIS. JQI 

in beine: confined more to the bronchi. Hence it is that the 
secretion is pituitary rather than mucous, and that in the form 
now considered, it occurs exclusively among the infirm and 
aged, who cannot support any high degree of inflammation. 
The lividity proceeds from an imperfect decarbonization of the 
blood. 

TREATMENT. 

Venesection, when it can be borne. The detraction should 
be small, and it may be repeated if it is beneficial. 

Active Vomiting, — Very appropriate to an early stage. 
Should not be used where there is gastric complication. 

Cups, between the shoulders, and to the sides, may succeed, 
if necessary, the emetics. 

A Blister of large size to the breast. 

Calomel Purges, though in contrariety to an antiquated 
prejudice against the use of purges in pulmonary complaints. 

Calomel, Opium, and Ipecacuanha. — Or, the opium, 
which here never does harm, may be united with the squill, 
gum ammoniac, or senega. 

R. — Decoct. Rad. Senega?, 3vj. 
Mel, 3j. 

Tinct. Opii. Comp., gss. 
Dose, a fluid ounce every two hours. 

The Antispasmodics, and in an extremity, the 
Carbonate of Ammonia, and Hot Wine Whey. 

As palliative may be employed the vapour of hot water, or 
hot water with the addition of vinegar, or tincture of tolu (an 
ounce to the pint), or iodine. The sensibility of the glottis and 
mucous surface being diminished, we may try the vapour of 
Hoffman's anodyne liquor, or the spirits of ammonia. 



BRONCHITIS CHRONICA, OR CHRONIC 
BRONCHITIS. 



SYMPTOMS. 

A dull, uneasy sensation, usually under the sternum ; cough, 
expectoration of glairy or frothy phlegm, sometimes becoming 
puruloid, or purulent, though oftener gleety, and still more com- 
monly unchanged in character, but augmented in quantity, — 
attended with heavy dyspnoea, and constant wheezing and 
rattling. 

Pulse feeble; skin pallid and damp, with a tendency to 
oedema. 

Thus, with occasional fluctuations, may the disease run on 
for years. 

Death may occur from suffocation, or dropsy, or absolute 
exhaustion, or hectic irritation. 

CAUSES. 

An ill-cured acute affection ; cold and humidity operating on 
a lymphatic constitution, or on a constitution vitiated by intem- 
perance, gout, &c. 

To dyspepsia, chronic hepatitis, and, perhaps, to worms, is it 
sometimes owing. 

DIAGNOSIS. 

Distinguish by the wheezing and rattling, the pallor, flacci- 
dity of skin (and sometimes oedema of the face), and by the 
same auscultatory signs, as in acute bronchitis. 



CHRONIC BRONCHITIS. 183 

PROGNOSIS. 

Old, or complicated attacks, generally incurable. 

AUTOPSIC APPEARANCES. 

Organic alterations, — such as ulcerations, granulations, hard- 
ening, &c, — are discovered in the bronchia. The lungs are 
often hepatized, the abdominal viscera frequently found in a 
state of disease; and dropsical effusions are common. 

TREATMENT. 

In uncomplicated cases, occurring in sound constitutions. 

Tenesectio n. — The alternate application of C U p s to the hack, 
and B 1 i s t e r S to the chest. 

Small doses of Calomel, Ipecacuanha (or Squills), and 
Opium. 

C 1 C h i c U m may be serviceable in arthritic cases. 

The Balsams and Terebinthinates.— The patient having 
been prepared, on these must we place our chief reliance. They 
are particularly adapted to instances of a mucoid, purulent, or 
gleety discharge. 

Tonics. — When the discharges are thin and pituitary. 

The bronchitis being secondary, we must, of course, cure the 
primary affection. 



TUSSIS VEL CATARRHUS SENILIS. 



A form of chronic bronchitis, incident to old age. 

SYMPTOMS. 

Cough and defluxions. These, however, being inseparable 
from the conditions wrought by old age, hardly become objects 
of medical treatment. But being aggravated by a cold, the 
symptoms exhibit a morning and evening exacerbation, at 
which time the dyspnoea is distressing, the wheezing and rat- 
tling sonorous, the pulse feeble, skin cold, and countenance 
haggard. The disease may be frequently repeated upon fresh 
exposures, until the powers of life are expended. The disease 
is sometimes, however, continuous for years; and may be 
attended with immense secretions. 

TREATMENT. 

Being a modified form of chronic bronchitis, the same reme- 
dies are applicable ; to be employed, however, with less rigour, 
and to a less extent. 

REGIME N. 

In all these chronic bronchitic affections, the diet should be 
moderate, but nutritious; and, when the weather is dry, the 
patient should go about freely in the open air. 



INFANTILE BRONCHITIS, OB 
GATABBHAL FEVEB. 



A disease incident to children, and varying in nature between 
a catarrh and bronchitis, and entitled accordingly by one of the 
above-mentioned names. 

Generally met with, between the ages of two and three ; 
though often much earlier or later. 

SYMPTOMS. 

P R I M A R Y. — Beginning as a common cold, it may thus con- 
tinue several days. Yet there is some disposition to heaviness. 
Fever moderate, or entirely absent. 

SECONDARY. — Fever; dry, frequent cough, sometimes 
hoarseness, and constriction of the chest. 

T E R T I A R Y. — A state of collapse. After a series of remis- 
sions and exacerbations, the child sinks away in a comatose 
state, or suddenly perishes by suffocation. 

The affection has sometimes a bronchitic character from the 
commencement. Occasionally, other portions of the respiratory 
apparatus are involved; and at other times, by an extension of 
irritation, the primae vise are implicated. 

It is remarkable how prone these catarrhal and bronchitic 
affections are, to degenerate into effusions in the brain. 

CAUSES. 

Chiefly occasioned by vicissitudes of the weather. But it 
may prevail epidemically. 



186 



DISEASES OF THE RESPIRATORY SYSTEM. 



Phthisical children are most subject to the affection ; but the 
robust are very apt to contract the catarrhal variety. 

FortheDIAGNOSIS, PROGNOSIS, AUTOPSIC APPEAR- 
ANCES, and PATHOLOGY, the remarks on these subjects 
under the corresponding diseases of adults, will suffice. 

TREATMENT. 

IN THE CATARRHAL FORM, 

The leading remedy is 

Venesection. — Subsequently we may resort to the other 
measures recommended for the same state in a more advanced 
age. 



BUT IN THE BRONCHITIC FORM, 

Venesection is seldom allowable; giving rise to a state of 
collapse rarely overcome. Mostly, in this form, we should 
commence with, 

An Emetic. 

Calomel Purges. — The object is to produce revulsion to 
the intestines, and to arouse the secretory action of the liver, 
which is always more or less impaired. We should persevere, 
until we discover that welcome harbinger of amendment, dis- 
charges of bile. 

Cupping, at an early stage. 

The Antimonials, &c, while there is fever. 

Blisters, A Combination of Calomel, Opium, and 
Ipecacuanha, and Cutaneous Friction, with the Warm 
Bath, when vascular action has subsided. 

Collapse supervening, 

The Carbonate of Ammonia, Wine Whey, with 
Sinapisms to the Extremities. 



CHKONIC INFANTILE BRONCHITIS, ETC. 



The catarrhal variety has in it nothing singular. But the 
bronchitic form, and especially that popularly called phthisic, 
may clajm a slight attention. 

It is sometimes congenital, or manifested, at least, soon after 
birth, and is then often connected with a contracted chest, and, 
almost uniformly, with a phlegmatic temperament. 

Excepting a perpetual excess of bronchial secretion, with a 
wheezing and rattling, nothing is usually discovered, until an 
exasperation is induced by exposure to cold, when there is an 
accession of fever, with excessive pulmonary oppression. 

TREATMENT. 

The attack is to be managed like a case of common bron- 
chitis. 

In the interval of the attacks, a careful avoidance of the 
exciting causes, should be observed ; and tonic medicines and 
regimen become of service. 

The affection arising from malconformation, we can effect 
little. Puberty, however, sometimes developes a favourable 
change of structure. 



CYNANCHE TRACHEALIS, OR CROUP, 



Popularly called hives. Consists of an inflammation chiefly 
in the larynx in the commencement, and in the bronchia in the 
termination. 

The disease is mostly confined to early life; and the attack 
usually comes on at night. 

SYMPTO M S. 

AGGRESSIVE STAG E .— A dry hoarse cough, compared to 
the barking of a small dog. At this time there is no appreciable 
constitutional disturbance. The child soon relapses into a sleep, 
from which it is again aroused by the cough. Cases of this 
kind soon perish, if relief be not afforded. The attack, too, 
being apparently overcome, manifests a lively disposition to 
return a few hours afterwards, or, at least, the next night ; or, 
the disease may supervene as a cold. Catarrhs destitute of a 
defluxion, are very apt to become croup. 



ADVANCED STAGE,— An active tense pulse, flushed face, 
and hot dry skin ; the respiration audibly impeded, and distin- 
guished by a stridulous intonation, resembling cooing, or in some 
instances, especially when the case is somewhat farther ad- 
vanced, by a species of hissing. The cough becomes whooping, 
and is always without expectoration, or defluxion from the nose 
or eyes. The voice is hoarse, or whispering. The alimentary 
canal is remarkably insensible to remedies. The brain shows 
its affection by flightiness, or somnolency. 

Subsequently is expelled with difficulty, phlegm, or ropy mu- 
cus, or albuminous matter, which, while in the larynx, occasions 



CROUP. 189 

a wheezing, or rattling. Being thrown up, temporary relief is 
afforded. 

Henceforth the symptoms are those of slow suffocation. Yet, 
in the hawking which is sometimes made, the coagulated 
lymph, which had been effused by the larynx, is brought up, and 
a cure is effected. 

D U R A T 1 N. — The disease seldom exceeds two or three days ; 
and, may, when of the spasmodic form, terminate in a few 
hours. 

The inflammation sometimes travels down to the remotest 
ramifications of the bronchi. The case may also be compli- 
cated with engorgement of the lungs, phlogosis of their structure, 
or serous covering, or with oedema of the cellular texture. 

CAUSES. 

P R E D I S P S I N G.— The period of life between one and five 
years — (though the affection is probably incident to adult age). 
It seems to be sometimes hereditary. 

E X C I T I N 6. — A moist austere atmosphere. It seems endemic 
in certain situations. Thus, in Leith,the seaport of Edinburgh, 
it is frightfully prevalent; while in Edinburgh, about a mile dis- 
tant, it scarcely ever occurs. 

Irritation of the prima? vise. Spinal irritation. Mental emo- 
tions. 

Scarlet fever, by an extension of phlogosis to the larynx, some- 
times assimilates croup. 

DIAGNOSIS. 

It can hardly be mistaken by those who have once seen it. 

Chiefly does it resemble laryngismus stridulus, and cynanche 
laryngea, the distinctive marks of which will be pointed out, 
when these diseases are taken up. 

To discriminate the two varieties of croup — spasmodic and 
inflammatory — we need only advert to the mode of attack. 



190 DISEASES OF THE RESPIRATORY SYSTEM. 

The spasmodic form supervenes suddenly, and in children, and 
usually at night. It is betrayed by the clangorous or barking 
cough, and sometimes by manifestations of impending suffoca- 
tion. In adults, it is often induced by mental emotions. 

The inflammatory form approaches gradually, as catarrh, 
with slight or no defluxions from the nose ; and the croupy 
cough, when formed, is less clangorous. 

The creation of an adventitious membrane in the windpipe, 
may be inferred from a sensible abatement of intensity in the 
tone of the cough, the hoarseness degenerating into a whisper, 
the breathing appearing as if it were made through gauze, and 
the dyspnoea amounting to strangulation. On the other hand, 
the obstruction from a secretion less adhesive than plastic 
lymph, allows the same sort of wheezing and rattling which 
belong to catarrh or bronchitis. We may be aided by auscul- 
tation. 

PROGNOSIS. 

Treated early and judiciously, the prospect is good ; but, 
being confirmed, or the membranous exudation having been 
thrown out, or the lungs having become in any way implicated, 
the cure is exceedingly doubtful. 

AUTOPSIC APPEARANCES. 

At an early period, no lesion whatever may be observed ; or 
there may be merely evidence of pre-existing spasm of the 
glottis. 

At a more advanced period, there may be high phlogosis of 
the larynx. Its tissues may be only tumefied ; but more fre- 
quently there are extravasations of ropy mucus, or of coagulable 
lymph, — the latter in broken pieces, or constituting a tubular 
lining down through the trachea, and sometimes to the termi- 
nations of the large bronchi. This lining may be either a 
yellow pulpy matter, easily detached, or it may be very tena- 
cious, like pure lymph, and forming, as was formerly mentioned, 
an adventitious membrane. 



CROUP. 



191 



Besides, may be observed the evidences of those pulmonary 
complications already alluded to. 

PATHOLOGY. 

The almost entire insusceptibility of adults of the disease, is 
attributed to that mutation, which takes place in the larynx 
about the age of puberty, and is evinced by the enlargement of 
its calibre, and the deepening and strengthening of the voice. 

The affection may either be spasmodic or inflammatory. Its 
spasmodic nature is demonstrated by its occasionally super- 
vening in a moment, and being connected, as appears from the 
necroscopy, with no inflammatory appearances. But the spasm 
is soon converted into an inflammation. 

The extravasation of coagulable lymph in croup, when it 
does not take place in catarrhal inflammation of the same part, 
is attributable to the superior intensity of phlogosis. 

In the croup of children, there is a greater inclination to the 
effusion of coagulable lymph ; which results from the greater 
proportion of fibrin existing in those whose system is still in a 
state of growth. 

TREATMENT. 

Dr. Chapman's mode is simple, and so successful, that he 
never lost a case, to which he was early called. 

Whether the affection be a spasmodic irritation or phlogosis, 
the management may be identical. No allusion, however, is 
now made to the hysterical and neuralgic forms, which occur 
in advanced life. 

Nauseants and a Sinapism to the neck, sometimes arrest 
the disease in its forming stage. The smoking of a cigar, or 
the snuff plaster to the breast, has been here recommended. 
But the former is inapplicable to children, and the latter is 
unsuited, from its occasional incontrollably depressing effects. 

These failing, w 7 e endeavour at once to produce 

Free Vomiting. — The syrup of ipecacuanha is preferable 
for ordinary use. Tartar emetic, somewhat dangerous in the 



192 DISEASES OF THE RESPIRATORY SYSTEM. 

insensibility of stomach incident to croup, may, however, be 
added, when necessary to induce emesis. But the surest emetic 
combination, is a union of ipecacuanha, tartar emetic, and 
calomel. The emetic may be given in divided doses. An in- 
creased susceptibility to the emetic may be created by a 

Warm Bath, which is itself curative in tendency. But the 
emetic not operating, or having operated, not producing the 
desired effect, we may resort to 

Copious Venesection. — This may be followed with a re- 
petition of the warm bath. The croup, now, nearly always 
yields. But continuing, we direct 

Topical Bleedin g. — Cups being used, they should be ap- 
plied to the sides, or the back of the neck. 

A Blister. 

The foregoing measures proving still unavailing, Dr. Chap- 
man employs 

Bleeding ad deliquium animi. — In the early period of 
the disease, he has never known this to fail. Even where the 
phlogosis is not cured by it, there results an extravasation of 
thinner and less tenacious substance than plastic lymph. 

Purgation by Calomel. — To be employed when the dis- 
ease is somewhat broken. It destroys the lingering symptoms, 
and confirms convalescence. 

Polygala Senega is a useful expectorant, when there is 
still much hoarseness and tightness of chest. 

But from neglect, or inadequate management, it may happen 
that at this time, the forces of life being enfeebled, the disease 
is still unsubdued. In this conjuncture, Dr. Chapman recom- 
mends diaphoresis, produced by the 

Dover's Powder and Tap our Bath. 

But depletion having been inadequately resorted to, the case 
may, at this period, be complicated with the exudation of a 
tenacious mucus, or plastic lymph, the latter sometimes forming 
a false membrane. Here we endeavour to expel the exudation 
by placing the child in a warm bath, and at the same time ex- 
citing vigorous emesis by some stimulating emetic. Yet the 
plastic lymph, especially if membranous, is very seldom de- 
tached. 



CROUP. 193 

The subsequent treatment consists of the pretty constant use 
of the stimulating expectorants. But perhaps more will be 
gained from calomel in small doses, which instituting a copious 
secretion of a thin fluid, may separate the tenacious mucus, or 
lymph, or even the false membrane. Dr. Chapman recom- 
mends the use of small doses of tartarized antimony, in connex- 
ion with the calomel, which he thinks promotes the specific 
action of mercury. 

These measures being ineffectual, as they probably will be, 
our only resource is in tracheotomy. Yet the disease has usu- 
ally implicated to such a degree the lower part of the trachea, 
and the bronchia, that little is to be gained by the operation. 
The affection, however, is sometimes restricted to the larynx ; 
and there have been many instances reported of the operation 
having been followed with a permanent cure. 

For the expulsion of the adherent secretion, sternutatories 
have been proposed. It occurred separately to Dr. Chapman 
and to Dr. Physick, that it might be detached by the introduc- 
tion of a bougie. 

Croup being secondary to an inflammation of the fauces, the 
latter should be touched with a strong solution of the nitrate of 
silver, or with burnt alum. 

It is the practice of many of the European, and, particularly, 
the French physicians, to waive venesection in this disease. 
But, according to their own confessions, the mortality of their 
patients is awful. 

Most erroneous is the common notion that children will not 
well bear depletion. The truth is, they bear some of the active 
remedies much better than adults, — especially vomiting, purging, 
and the loss of blood. This, indeed, apart from experience, 
might, from their high proportion of blood, and particularly of 
the fibrinous element, from their great recuperative power, their 
tenacity of life, and their predisposition to inflammatory com- 
plaints, be predicated of them. 

13 



LARYNGISMUS STRIDULUS, OR ACUTE 
INFANTILE ASTHMA. 

First noticed in 1769, by an English writer, of the name of 

Millar. 

SYMPTOMS. 

The child wakes up, in an apparently suffocating condition. 
This state, having lasted a few minutes, gives way, and is succeed- 
ed by a long, full inspiration, attended sometimes with a whoop- 
ing or a crowing noise, like that of croup. After much agitation, 
the child sinks into a sweet sleep, or attended only by tempo- 
rary sobbings. On waking it is well, or is cross, or dull and 
drowsy, which state quickly wears away, or there may be a 
repetition of attacks in rapid, or more distant succession, for an 
indefinite period. Each paroxysm then is lengthened and some- 
times leads to general convulsions, in which the fingers and 
toes are spasmodically contracted. Death may take place in 
such paroxysms ; or they may be followed by a state of lethargy. 
In some protracted instances they bear the apoplectic character. 
A very slight constriction of the glottis sometimes induces this 
state. The disease is then apt to run a lingering course, the 
paroxysm recurring every hour or two, or at intervals of days, 
or weeks. It may observe, with considerable regularity, a 
quotidian, tertian, or quartan recurrence. 

In the acute disease, fever is never betrayed ; but, in pro- 
tracted instances, some vascular excitement and determination 
of blood to the head, may be exhibited. 

CAUSES. 
Laryngismus, in Dr. Chapman's experience, has been con- 



INFANTILE ASTHMA. I95 

fined to childhood, and chiefly within the period of dentition; 
the spasm of the glottis in adults, differing in several respects. 

THE GREAT PREDISPOSING C A U S E, is probably a pe- 
culiar irritability of the respiratory tube, and smallness of its 
calibre. 

EXCITING CAUSES are mental emotions, and irritation of 
the primae viae. 

DIAGNOSIS. 

It is distinguished from croup by its momentary nature, and 
its being followed by no inflammation, and from asthma, by the 
breathing being stridulous and dry, instead of wheezing and 
rattling. 

It differs from a similar closure of the glottis in adults, in the 
latter resulting from a highly-wrought nervous condition. 

PROGNOSIS. 

In its milder forms, manageable. But the reverse is true, 
when the paroxysms become very numerous, and are connected 
with cerebral disturbance, and when the affection is complicated 
with dentition. 

AUTOPSIC APPEARANCES. 

Congestion, serous effusion, or structural changes of the brain ; 
engorgement of the lungs; and sometimes the thymus, or other 
glands about the neck, in a state of enlargement. But, occasion- 
ally there is no lesion whatever. 

PATHOLOGY. 

The common notion in regard to this subject, is, that the 
spasm is excited by the compression of the recurrent or inferior 
or laryngeal branch of the par vagum, from tumours. But it is 
doubtful whether the compression of tumours, if they should be 
sufficient to affect the nerve, would not rather produce paralysis. 



196 DISEASES OF THE RESPIRATORY SYSTEM. 

The spasm, too, in such a case, being produced by a permanent 
cause, should recur more frequently. But, above all, how often 
do we see the disease without any such tumours, and, con- 
versely, how often do we see such tumours without the disease ! 

Dr. Chapman places the seat of the disease in the cerebro- 
spinal axis. In the progress of the case, it is apt to be concen- 
trated in the brain. The affection may either be original to 
these nervous centres, or it may arise primarily from irritation 
in the alimentary canal. The analogous cases of adults, are 
confessedly the result of cerebro-spinal disease ; and such they 
have often been demonstrated, by dissection, to be. 

It is likely that the affection differs in no wise from the ordi- 
nary fits of children, except in the casual accompaniment of 
spasm of the glottis. 

TREATMENT. 

The paroxysm is usually so transient, that little can be done 
for the relief of the spasm. Strong counter- irritation, with the 
aqua ammonia? applied along the windpipe, may be serviceable. 

In the intermission, 

Bleeding, General and Topical. 

Warm Bath. 

Emetics, and Purgatives. 

R e v u 1 s i v e s to the lower extremities, with Cold Applica- 
tions to the Head. 

Counter-irritants to the head. 

The primary point of irritation being in the alimentary canal, 
the emetics and purgatives are to be used first. There being 
worms, these are to be 'first destroyed by anthelmintics. The 
gums are to be incised in the case of dentition. Such remedies, 
however, having been premised, the employment of opiates will 
•be often beneficial. These are sometimes eminently valuable 
in quieting irritation of the brain, especially when arising from 
■disorder of the primse viae. 



PERTUSSIS, OR WHOOPING COUGH. 



Was first observed in France in 1414. Almost exclusively 
incident to childhood. 

SYMPTOMS. 

AGGRESSIVE.— May begin like an ordinary cold, with 
more or less fever, which, though it usually soon ceases, some- 
times continues throughout the course of the disease. 

MORE ADVANCE D .— Commonly, in from ten days to two 
weeks, the sonorous inspiration or whooping commences. The 
affection now becomes strictly paroxysmal. An attack is pre- 
ceded by tickling of the throat, constriction of both the larynx 
and chest, and a sense of suffocation. Each paroxysm is com- 
posed of a quick succession of sonorous expirations, with 
scarcely, for a considerable interval, any perceptible inspiration. 
The expiration, however, becomes, at length, suddenly inter- 
rupted by a deep, convulsive, noisy inspiration, accompanied 
by a lengthened hissing, ending usually by vomiting, or by an 
expectoration of phlegm. In some paroxyms, so great a con- 
gestion of the head takes place, that the blood issues from the 
mouth, nose, eyes, or ears, or it may eventuate in convulsions. 

The paroxysm is sometimes very soon over. At other times, 
it lasts from five to ten minutes. 

At this time, the intermission between the paroxysms is 
usually a period of health ; though sometimes there is exhibited 
derangement of the respiratory, digestive, and nervous systems. 
But such derangement is more commonly met with in a subse- 
quent stage. 



198 DISEASES OFTHE RESPIRATORY SYSTEM. 

The number of paroxysms may, in the beginning, not exceed 
two or three daily; while at the height of the disease, there 
may be so many as one every hour. 

The affection may terminate indefinitely in from one to three, 
or even six months. 

CAUSES. 

The affection depends on a contagion, which rarely affects 
the same person more than once. It is also much subject to an 
epidemic influence. 

DIAGNOSIS. 

It is distinguished from catarrh by the paroxysmal nature, 
and other peculiarities of the cough ; generally by the absence 
of fever, and, when fully developed, by the whooping nature of 
the cough. 

PROGNOSIS. 

The disease may terminate in death from apoplexy, convul- 
sions, or suffocation, or it may result in some other affection of 
the respiratory apparatus, or disease of the brain. 

AUTOPSIC APPEARANCES. 

Inflammation of the larynx and bronchia, congestion, inflam- 
mation and effusions in the brain, lesions of the spinal marrow, 
and depravations of the digestive organs, especially of the 
mesenteric glands. 

PATHOLOGY. 

The seat of the disease has been placed by different writers 
in the bronchia, either in their larger trunks, or their minute 
ramifications; in the larynx; in the pharynx; in the spinal 
marrow, or brain ; and in the alimentary canal. 



WHOOPING COUGH. 199 

Again, one set of pathologists aver that the nature of the 
action is purely spasmodic; while another aver it to be actively 
inflammatory. 

Most obviously, however, the affection originates in spas- 
modic irritation, which, by protraction, may induce phlogosis 
of the mucous membrane of the different parts of the organs of 
respiration, occasioning an increased secretion, variously vitia- 
ted, which, accumulating, may act as an extraneous irritant, 
and bring on the cough for its expulsion. 

But, from the peculiarity of the cause producing it, the inflam- 
mation of the pulmonary and other structures is specific. 

The sonorous inspiration proceeds from spasm of the glottis, 
and perhaps ultimately from tumefaction of the lining tissue 
from phlogosis. 

The primary point of irritation is probably in the spinal mar- 
row, especially the upper part; though it is, possibly, first seated 
in the respiratory or gastric surface, and be thence reflected 
from the spinal marrow, by reflex action, as it is called. 

TREATMENT. 

This, like all other diseases dependent on a specific conta- 
gion, is governed by its own peculiar laws, and has proved 
very intractable to our efforts. Sometimes the affection is so 
mild as to require very little or no treatment. 

The two indications are to restrain the violence of the disease, 
and to overcome the morbid habit which keeps it up, when the 
cause having produced it, is expended. 

Venesection, — When there is fever with local congestion, 
or phlogosis. 

Local Blood-letting and Blisters, to the back of the 
neck, or between the shoulders. 

Emetics. — Adapted to the cases of children. May be re- 
peated once a day. 

Calomel Purge s. — The tendency to constipation may also 
be overcome by castor oil. But the calomel purges are other- 
wise useful. 

Nanseant s. — To promote expectoration. 



200 DISEASES OF THE RESPIRATORY SYSTEM. 

At this stage, a great deal of trust has been reposed in the 
following counter-agents; which, however, Dr. Chapman re- 
spects very slightly. 

The Fixed Alkalies, may perform the same service, 
which they do in common catarrh. 

The Narcotics, and Antispasmodic s. — These may 
be palliative. 

To break up the morbid association, on which the disease 
ultimately depends, is the next indication. 

Sulphate of Quini a. — This deserves a fairer trial than 
it has received. 

Arsenic, — Highly appreciated by Dr. Chapman, particu- 
larly when united with laudanum. 

The sulphate of copper has probably a similar efficacy. 

I r n, — This is nearly always preferred by Dr. Chapman. It 
may be combined with quinine. 

The tincture of cantharides was highly recommended by Dr. 
Physick. It w r as used until strangury was produced. 

Dr. Chapman considers it of great importance to obviate the 
various lesions which may exist in the respiratory organs, sto- 
mach, brain, spinal marrow, &c. 

Of much benefit is freely going out in the open air, when the 
weather is favourable. 

Vaccination has been said to be a counter-agent. 

REGIMEN. 

A febrile or inflammatory state existing, the diet should be 
low, and every other part of the antiphlogistic system should 
be observed. The strictest care should be taken, to avoid 
catching cold. 






CYNANCHE LARYNGEA, OR ACUTE 
LARYNGITIS. 



Was formerly confounded with croup ; yet it must be con- 
sidered a rare disease. 

It is the disease of which died Washington, and the Empress 
Josephine. 

SYMPTOMS. 

INCIPIEN T. — Chilliness ; huskiness of the throat ; hawking ; 
inspiration impeded, and attended with a whistling noise; no 
regular cough ; voice hoarse, or whispering ; pain on pressure 
of the pomum Adami, and some fever. 

Or, the disease may commence as a catarrh, or as gastric 
irritation, which by metastasis is thrown upon the larynx. 
Again, it may begin as tonsillitis. 

There is a variety, moreover, in which, in place of inflamma- 
tion, there is effusion in the subcellular tissue, called laryngitis 
oe.dematosa. 

MORE ADVANCE D. — An aggravation of the preceding 
symptoms; a sinking, diminutive pulse; cold collapsed skin; 
strangling produced by an attempt to swallow ; and the most 
violent paroxysmal dyspnoea. 

The average duration of the disease is from two to five days, 
though it may terminate within a few hours. 



202 DISEASES OF THE RESPIRATORY SYSTEM. 



CAUSES. 

Occurs more among males than females; among adults and 
the old, than the young. 

It is brought on by exposure to a cold, austere atmosphere, 
and by whatever directly, or indirectly, irritates the larynx. 

DIAGNOSIS. 

Distinguished from croup, by the diffusively inflamed fauces, 
tenderness of the larynx, difficulty of deglutition, absence of 
cough and raucal intonation, and by the period of life. 

In pharyngitis, the respiration is unaffected. 

PROGNOSIS. 
One of the most unmanageable diseases. 

AUTOPSIC APPEARANCES. 

Where death occurs from spasms, no lesion is sometimes 
discoverable. But oftener, the lining membrane is found red 
and turgid, the sides of the glottis approximated, the epiglottis 
sometimes swollen and erected, and effusion of serum, lymph, or 
pus in the subcellular tissue. 

The trachea is seldom affected. The bronchi are occa- 
sionally choked up with secretions, and the lungs cedematous, 
inflamed, or congested. 

PATHOLOGY. 

The disease consists in a mixture of inflammation and spasm 
in the upper part of the windpipe. In this respect it much re- 
sembles the early stage of croup. But while the latter is so 
tractable, why is the former so intractable 1 In croup the inflam- 
mation is in the mucous tissue, while in laryngitis it is chiefly 



ACUTE LARYNGITIS. 203 

in the cellular tissue beneath. Mere swelling from phlogosis 
is generally great enough in this tissue, to cause the symptoms 
mostly exhibited in laryngitis ; but occasionally an effusion 
takes place, which produces extreme constriction of the passage. 
The remedies adapted to the removal of the false membrane, 
which is the most striking peculiarity of croup, are not adapted 
to remedy the disorder in the cellular tissue. 

The effusion in laryngitis is usually of serum, but in croup it 
is of fibrin ; — which well concurs with the respective ages to 
which the two diseases are most incident. In vouth, fibrin 
being wanted to supply the growth of the economy, is abundant ; 
but the physical developement having been completed, it be- 
comes comparatively deficient. 

TREATMENT. 

To overcome phlogosis, so as to prevent suffocation from the 
closing of the glottis by it, or by the cedematous state subse- 
quently induced, is the great object of treatment. 

Venesectio n. — Ad deliquium animi. It should be carried to 
the extent, not merely of abating action, but of subverting it. It 
should be performed also immediately, lest effusion supervene, 
which will render it nugatory. 

An Emetic of tartar emetic, ipecacuanha, and calomel. 

leeches. 

Emollient Poultice s. 

A Blister. 

The Inhalation of the Mildest Vapours. 

A Calomel Purge. 

The antispasmodics have been suggested for a relief of the 
spasm. Dr. Chapman, admitting that they might be beneficial 
upon a reduction of action, regards them, still, as doubtful reme- 
dies, and has not used them. 

Tobacco Cataplasm to the neck, or the smoking of tobacco, 
where the individual is unaccustomed to its use, is of the highest 
utility in relaxing spasm ; and is, perhaps, conducive to the sub- 
jection of the inflammation. 



204 DISEASES OF THE RESPIRATORY SYSTEM. 

Depleting measures being no longer allowable, resort to sweat- 
ing with the Dover's powder, and vapour bath, for several hours. 

We here should endeavour to discover from physical explo- 
ration, whether a part of the affection may not be owing to con- 
gestion or cedema of the lungs. 

The antimonials may be used with a view of further reducing 
the phlogosis; and with the same view may we resort to a com- 
bination of calomel, opium, and ipecacuanha, which Dr. Chap- 
man predicates to be useful from its confessed efficacy in the 
cure of reduced states of inflammation generally. 

Cases have been alluded to where at first an oedematous dis- 
position is manifested in the throat, descending afterwards to the 
larynx. These cases, Dr. Chapman is convinced, belong to the 
lymphatic temperament, and will not bear the loss of blood, 
except, perhaps, a few leeches in the commencement. Emetics, 
a blister to the neck, and touching the fauces with a strong solu- 
tion of lunar caustic, or with the powder of burnt alum, are 
particularly serviceable. 

Dr. Chapman has suggested the plan, when effusion has taken 
place, of cutting down into the cellular tissue, and evacuating 
the fluid. 

Laryngotom y. — This should not be performed too early, 
lest the inflammed condition of the larynx be aggravated by the 
incision, nor should it be delayed until sinking occur. 

The operation having been performed, the quiescence enjoyed 
by the most inflamed part of the larynx is favourable to its cure. 
The inflammation and tumefaction having subsided, the artificial 
passage may be allowed to heal. New and improved opera- 
tions have been invented by Physick, and Carmichael. The 
chance of success in an operation is greater in the case of 
laryngitis than in croup, in consequence of the rarity of an exten- 
sion of the inflammation to the lungs. Of successful operations 
for croup, Dr. Chapman has collected eleven, for laryngitis, 
eighteen instances. 






CHRONIC LARYNGITIS. 



This term is used to express a series of chronic degenerations 
of the windpipe, of which the symptoms have usually no great 
resemblance to the acute affections of the same structure. The 
term includes the lesions of both the larynx and trachea. 

SYMPTOMS. 

The most mitigated form is when the only symptom presented 
is hoarseness. This affection may last a lifetime without any 
deterioration. 

INCIPIENT. — But in laryngitis proper we have usually an 
insidious approach, manifested by the following symptoms. — 
Huskiness of the fauces; difficulty of swallowing; a short, dry, 
worrying cough; hoarseness, pain, and embarrassment in 
speaking ; a failing of the voice when elevated ; a deterioration 
of it experienced from a transition to either a cold or hot tem- 
perature; uneasiness or stiffness in the larynx, speedily con- 
verted into a stinging pain, with a constant propensity to gulp ; 
sometimes pain on pressure ; spasmodic paroxysms of coughing, 
with a particular wheeze on inspiration; commonly derange- 
ment of the stomach and bowels ; an appearance in the throat, 
when examined, of injection, granulation, aphthous ulceration, 
hypertrophy of the tonsils, or of elongation and other changes 
in the uvula. The system, at this period, betrays its disorder 
only by irritation of pulse, flaccidity of the skin, and diminution 
of muscular power and mental energy. 

MORE ADVANCED SYMPTOMS,— Violent inspiration; voice 



206 DISEASES OF THE RESPIRATORY SYSTEM. 

very rough, or lost in an indistinct whisper ; periodical dyspnoea ; 
a hawking up of ropy, or thin mucus, sometimes mixed with 
puriloid, or purulent matter; and spasm in the windpipe, occa- 
sionally proving fatal. 

Or the disease may linger along, simulating genuine consump- 
tion, and bearing the title phthisis laryngitis. Here the irrita- 
tion extends to the chest, and is followed by hectic. 

CAUSES. 

Rarely occurs in females. Dr. Chapman ascribes the fre- 
quency of its attacks on clergymen, to an original imperfection 
of constitution, which he regards as more common among them, 
than others. 

The predisposition, he thinks, is laid in the lymphatic tempe- 
rament, coupled with a false nutrition ; though it also often rests 
upon a vitiated habit of body, and particularly on irritated or 
depraved states of the chylopoietic viscera. 

The system being vitiated, the disease may be induced by 
any irritant of the larynx. It may result from the repercussion 
of acute or chronic eruptions, or to an extension of phlogosis 
or ulceration of the fauces, either common, scrofulous, syphilitic, 
mercurial, or scorbutic, &c. 

It is often excited by an elongated uvula, or the irritation of 
a neighbouring tumour, or carious teeth. It is also, at times, 
tubercular, and may then be either followed or preceded by 
pulmonary phthisis. It may be generated by inordinate speak- 
ing or singing. 

DIAGNOSIS. 

Distinguish by an ocular examination, from lesions about the 
fauces, which, by their irritation of the larynx, produce very 
analogous symptoms. Distinguish, by physical exploration, 
from phthisis pulmonalis, and certain forms of bronchitis. Take 
care, also, not to confound it with mere affection of the muscles 
or nerves concerned in the production of voice. 



CHRONIC LARYNGITIS. 207 



PROGNOSIS. 



Very unfavourable. Cases proceeding from a tubercular or 
strumous diathesis, almost hopeless. 

AUTOPSIC APPEARANCES. 

Inflammation of the mucous membrane of the larynx, though 
more usually granulations or small ulcers, particularly around 
the glottis. Conversions of the cartilages into calcareous matter, 
are sometimes met with. The subcellular tissue may be dense, 
or swollen with serous effusion, or may contain small abscesses. 
Tubercles may be discovered. 

In the trachea, also, may be found granulations, ulcers, or 
tubercles. 

TREATMENT. 

The case proceeding from elongated uvula, from syphilitic, 
or other contamination, &c, we endeavour to eradicate the 
cause. 

The remaining remarks relate chiefly to chronic laryngitis of 
the ordinary kind, in a sound constitution. The remedies are 
General and Local Bleeding, Counter-irritation, and 
the applying to the fances, by a brush, Burnt 
Alum, once or twice a day. This last is to be done, whether 
there be inflammation there or not, unless it be very severe. 
The modus operandi of the burnt alum, seems to be the setting 
up of a new inflammation of a healthy kind, which reaches, 
by extension, the larynx, and subverts the old. 

Depletory measures, however, do not always answer, even in 
the instances in which tonics are highly aggravatory. 

The Narcotics are of some value. 

C a 1 o m e 1, so given as to produce incipient ptyalism. Adapted 
to certain syphilitic and ordinary cases, but contra-indicated by 
depravity of the system. 



208 DISEASES OF THE RESPIRATORY SYSTEM. 

Emetics. — Suited to the inchoative stage, and cases asso- 
ciated with much affection of the fauces. 

Ulcers existing, the compound syrup of sarsaparilla, and the 
inhalation of certain vapours, as those of tolu, tar, iodine, or 
chlorine, have been recommended. 

The case being desperate, laryngotomy may be performed, 
a number of cases having turned out favourably under the ope- 
ration. 

The diet is to be accommodated to the state of the system, 
any thing stimulating being carefully avoided. Exercise should 
be observed, when the subsidence of phlogosis, and the mildness 
of the weather, permit. The voice should be but little employed, 
and never strained. The temperature should be equable. 



PLEUROPNEUMONIA. 



By this term is signified an inflammation of the pleura, and of 
the cellular or interstitial tissue of the lungs, or, in other words, 
that tissue between the pulmonary cells. These two inflamma- 
tions may exist separately — that is, we may have simple pleu- 
risy, or simple pneumonia — but they usually coexist, and can be 
more briefly disposed of when viewed together. By Andral, 
the proper seat of pneumonia is attributed to the air-vessels and 
minute bronchia ; and Dr. Chapman admits that by extension, 
the inflammation may comprehend these parts. 

This disease presents either an inflammatory, or more rarely a 
typhoid character, which latter is to be hereafter considered. 

SYMPTO M S. 

INCEPTIVE.— Chilliness followed by fever, though the local 
affection may precede. The latter is, in the formative stage, 
apt to shift its position, and resemble in the soreness and aching 
of the muscles, an attack of rheumatism. Finally, however, 
being fixed in the thorax, we have the 

STAGE OF FULL D E V E L P E M E N T,— Heavy oppression ; 
acute lancinating pains, or stitches in the chest, much aggra- 
vated by a deep inspiration, or coughing, or a recumbent pos- 
ture. Early in the attack, the pain is increased by lying on the 
affected side ; but the acuteness of the attack having subsided, 
and effusion having taken place, to such an extent as to inter- 
rupt the function of the diseased lung, a lying on the affected 
side is assumed, for the purpose of affording all possible free- 
dom of expansion to the sound lung. The pain is sometimes 
sympathetically communicated to the sound side. Occasionally, 

14 



210 DISEASES OF THE RESPIRATORY SYSTEM. 

even in the most violent inflammations, it is entirely absent, or is 
obtuse and gravative. The more acute and piercing the pain, the 
more may the pleura be judged to be implicated. 

Inspiration usually hurried and jerking, attended by a hard, 
dry cough, stifled on account of pain arising from it ; expecto- 
ration deficient and consisting of frothy phlegm, or thin mucus, 
though it may gradually become a glutinous, tenacious mass of 
diverse hues ; greenish or yellowish, or varying from a light 
reddish to rusty colour. 

Pulse strong and active, skin hot, headache, and sometimes 
even delirious wanderings. Great thirst. 

FINAL STAGE. — Increased dyspnoea ; flagging pulse; re- 
duced muscular strength ; low animal temperature ; coma, with 
low delirium ; checked expectoration, though there may be 
sounds indicating accumulations of the secretions in the air-pas- 
sages. The symptoms are, however, regulated somewhat by 
the mode of termination, in hydrothorax, or pulmonary ab- 
cess, &c. 

Either pleurisy or pneumonia may proceed to a fatal termi- 
nation without a single manifestation. 

D U R A T I N. — By prompt and efficient treatment, may be 
soon cut short ; but is, when otherwise treated, apt to be linger- 
ing, and, according to Andral, to terminate on the seventh, 
eleventh, fourteenth, or twentieth day, by a deposit in the urine, 
or by perspiration. 

CAUSES. 

The disease is most incident to the robust, and those in the 
prime of life. 

EXCITING causes, are those of the phlegmasia? generally; 
and among others, metastasis, or misplacement of gout, or rheu- 
matism. Pleurisy, and pulmonary abscess, are both apt to fol- 
low great surgical operations, and are then not plainly charac- 
terized by symptoms, are rapid, and almost invariably fatal. 



PLEUROPNEUMONIA. 2H 

But the great exciting cause, is the damp, austere weather of 
spring, or winter. Intense cold, itself, is a cause, and proves 
more operative when gradually, than when suddenly applied. 
It may also occur with great violence in the summer, in conse- 
quence of exposure to drafts of air ; of working, especially 
when fatigued, in cold cellars, &c. 

As an epidemic, it spreads to a wide extent, and in a typhoid 
form. 



DIAGNOSIS. 

t 

Distinguished from other pulmonary affections by the activity 
and force of the circulation ; the breathing with the diaphragm 
rather than the costal muscles; the peculiar sputa, and the 
degree of pain. 

When the pleura is alone inflamed, the pulse is hard, corded, 
vibratory, and accelerated ; the breathing quick, short, and 
restrained ; the pain sharp and lancinating, apparently super- 
ficial, and aggravated by deep inspirations or coughing, or 
pressure in the intercostal spaces; the cough frequent and dry, 
or the sputa deficient and glairy. The pleural covering of the 
diaphragm being phlogosed, the preceding symptoms are aggra- 
vated. The pain, in this instance more acute and spasmodic, 
is felt along the cartilaginous border of the false ribs, extending 
even to the flanks. The dyspnoea is excessive. 

The lungs, in substance, being alone inflamed, the pulse is 
fuller, slower, and softer; pain more around the mamma, or 
under the sternum, or sometimes at the epigastrium, or between 
the shoulders, and is obtuse, heavy, and deep-seated. Greater 
labour, though less suffering, is betrayed in respiration ; cough 
is not so constant and violent; expectoration freer, and the 
matter raised thick and tenacious, and rusty or tinged with 
blood. 

Still the diagnosis is often incorrect. 



212 DISEASES OF THE RESPIRATORY SYSTEM. 



PHYSICAL SIGNS.— In Pleurisy. — Before effusion, 
the chest sounds naturally ; but this having occurred, the sound, 
on percussion, is dull. Where the layer of fluid is thin, the voice 
has, to an ear applied to the part, a sharp, tremulous sound, like 
the bleating of a goat, and is hence called agophony. 

By mensuration, the circumference of the affected side is 
sometimes half an inch longer than on the sound side. 

In Pneumoni a. — On percussion, the resonance is com- 
monly dull, or entirely extinct, as in pleurisy after effusion 
has occurred. Kespiration inaudible on the affected side, is 
puerile or anormally loud on the sound one. Crepitant or 
crackling rhonchus, owing to a mixture of the bubbles of air 
with the liquid secretion of the air-cells, is at first of very 
uniform occurrence. But as the disease proceeds the crepi- 
tant rhonchus disappears, the pulmonary cells being no longer 
permeable to the air. In the positions corresponding to the 
large bronchi, the breathing is cavernous, and the voice so 
resounds, as sometimes to produce a real bronchophony. Pus 
having been infiltrated through the cellular tissue, the rale 
crepitant is exchanged for the rale muqueux. The pus col- 
lecting at a spot, so as to form an abscess, the rattle be- 
comes cavernous, with a gurgling sound, and when the matter 
is discharged, the bronchophony is changed into pectorilo- 
quism. 

PROGNOSIS. 

More unfavourable in regard to infants, or the old, or those 
with a phthisical taint; and almost uniformly fatal to the con- 
firmed drunkard. Simple pleurisy is easily cured. 

In pneumonia, when resolution is taking place, the case 
retraces the steps by which it advanced. 

The thick yellow sputa constitute the means by which the 
lungs seem to be relieved of their inflammation. 

Unfavourable signs, are the supervention of diarrhoea in an 



PLEUROPNEUMONIA. 213 

advanced stage, and of excessive secretions, with a sense of 
suffocation ; besides a number of other things, easily suggested 
by what has been already said. 

AUTOPSIC APPEARANCES. 

The pleura reddened in points, or streaks, and coated here 
and there with coagulable lymph; or the pleural cavity dis- 
tended with a serous fluid, or blood, or pus. The collection of 
pus in a pleural cavity, is called empyema.* 

The lungs, when cut into, are seen to be reddish, and infil- 
trated with a frothy sanguineous serosity or lymph, though still 
cellular and crepitant. 

But the phlogosis having proceeded to a higher extent, the 
lung approaches more the liver in complexion and solidity, 
having lost its crepitant feel, from an obliteration of the cells. 
An incision being made, it appears spotted with red, white, and 
black; and being held before the light, the cells seem filled with 
small points resembling granulations. This state, from its re- 
semblance to the liver, is called hepatization, which is, according 
to the colour, either red or gray hepatization. The gray indi- 
cates the existence of a higher inflammation than the red. A 
still more solid state may be discovered, which, from its resem- 
blance to flesh, is called calcification. Again, the internal part 
may be a pale yellow, and discharge on pressure a puriloid or 
purulent fluid. An imposthume or pulmonary abscess, is very 
rare. 

There is a species of the disease, in which the inflammation 
does not traverse the membrane which separates the lobules of 
the lungs, and seems to originate in several points simultaneously. 
This is called lobular pneumonia. 

There may be also ramollescence, or gangrene, which is dis- 
tinguished by its terrible stench. 

Several of these states are generally more or less blended. 

In children, there is a greater disposition to lobular pneu- 
monia. 

Double pneumonia, or that existing in both lungs, is the most 



214 DISEASES OF THE RESPIRATORY SYSTEM. 

common form in the old and very young. The right lung is 
more subject to inflammation than the left; though the reverse 
holds, in respect to the pleurae. 

The mucous membrane, or other organs, are sometimes im- 
plicated. 

TREATMENT. 

A bold and prompt practice is, in this disease, urgently de- 
manded. 

Vcnesectio n. — Should be copious, and the blood should be 
drawn in a large stream. Faintness, which is a desirable ob- 
ject, is soonest procured, when the patient stands, and a vein is 
opened in each arm simultaneously. Yet, since the blood gene- 
rally needs a considerable reduction, these resorts are mostly 
unnecessary. 

Called at the height of an attack, we should not tie up the 
arm, until the pain remits, and the respiration is relieved, even 
though fifty ounces of blood be exacted for the purpose. 

The chief exception to this freedom of depletion, occurs in the 
infirm, and, above all, in drunkards of a phlegmatic tempera- 
ment. In these last, where there is a predisposition to effusions, 
dropsy of the pleura or cellular tissue is apt to follow ; — together 
with delirium tremens, and oppressive secretions from the bron- 
chia. Although, in the advanced stages, the lancet may be less 
freely used, yet, whenever the pulse is active, the skin warm, 
the pain severe, acute, or gravative, the chest tight, and the 
respiration impeded, we are justified in resorting to venesection. 

The cupped and buffed condition of the blood is not to be too 
implicitly trusted; since the cup and buff are often absent in the 
early stage, when it would be right to bleed, and are present at 
an advanced stage in which it would be wrong. 

And again, the symptoms above-mentioned as calling for 
venesection, may be absent, in consequence of the disease being 
masked by certain states of the brain and nervous system, when 
the inflammation is intense. The legitimate symptoms are then 
unfolded by bleeding. 



PLEUROPNEUMONIA. 215 

Cupping, between the shoulders, unless the pain is circum- 
scribed at another point. 

Blister s. — Best applied, when a considerable reduction of 
vascular action has been accomplished. They may, however, 
be of service in the formative stage. 

Emetic s. — Valuable, perhaps, as secondary means. 

Purgatives, — Particularly useful, where the chylopoietic 
viscera are involved from miasmatic influence. Here calomel 
should be used. 

Diaphoretics. — The more stimulating are suited only to 
the forming or closing stages; but, at a more active period, 
we may employ the sedative diaphoretics. Among these, the 
tartar emetic has acquired an especial reputation. It was given 
by Rassori, and his followers, in doses varying from a scruple 
to several drachms in twenty-four hours. It is said, that after 
a few doses the stomach ceases to suffer from it. But given in 
such quantities, it is regarded by Dr. Chapman as replete with 
danger ; and it is now, after having had a trial, generally aban- 
doned in this city. Yet in small doses it is an important remedy. 

Opiates, should not be administered in an active stage. 
They are, however, well suited to relieve the cough, which at 
an advanced period causes a continuance of pain and want of 
sleep ; and at an earlier date, to the attacks of old persons, 
characterized by irritation of the bronchia, inordinate pituitary- 
secretions, or an aggravating spasmodic cough. Dr. Chapman 
also uses it early in the case of drunkards ; and invariably uses 
it when he practises venesection, in such instances. 

After the more violent symptoms appear to be very conside- 
rably reduced, there may continue tightness of chest, with a 
dry, short cough, difficult and penurious expectoration, slight 
pain, and irritated pulse. This case is best met by a combina- 
tion of calomel, opium, and ipecacuanha, repeated at short in- 
tervals. This remedy may be assisted by a moderate bleeding, 
and blisters. 

In order that concoction or the formation of that critical ex- 
pectoration by which nature relieves itself, may be induced, the 
vessels should neither be so vigorous as to secrete lymph, nor so 
debilitated as to effuse serum. In the former instance they must 



216 DISEASES OF THE RESPIRATORY SYSTEM. 

be reduced, and in the latter stimulated. Hence results the 
advantage, occasionally, of the more stimulant diaphoretics. 

As soon as a loose cough, and a free discharge of thick tena- 
cious mucus appears, the disease may be considered as broken, 
and treated as if it were originally of a catarrhal nature, with 
the demulcent drinks and cough mixtures formerly mentioned. 

At this period, we sometimes meet in the aged, or infirm, 
dyspnoea, and other symptoms of effusion. This condition, with 
the other sequela; of the affection, will be hereafter more dis- 
tinctly noticed. 

The patient sinking from exhaustion, we should immediately 
resort to the carbonate of ammonia and hot wine whey. 



TYPHOID OR CONGESTIVE PNEUMONIA. 



That form of it, which constitutes a secondary affection of 
certain fevers, has been already treated of. The form now to 
be considered is what is called Pneumonia Biliosa. This is 
popularly termed bilious pleurisy, and is exceedingly prevalent 
in our country. 

SYMPTOMS. 

The characteristics of common pleurisy, or pneumonia, with 
a sparing expectoration of phlegm or mucus of a bilious colour, 
and very apt to be tinged w T ith dark blood, and other slight 
modifications. But to these symptoms are added many of the 
features of our autumnal fevers. From the intensity of the 
headache, the disease has been popularly called pleurisy of the 
head. 

The fever remittent, or even intermittent in the beginning, 
gradually becomes more continued and typhoid. 

Generally, the pulse is, at first, full, slow, struggling, and 
remarkably compressible ; the cutaneous surface pale, or mot- 
tled, hot, or cold, with clammy perspiration, or the temperature 
is very unequally diffused. Not arrested, the case proceeds to 
prostration, exhibiting the lowest forms of cerebral disturbance, 
and difficult respiration, with wheezing and rattling as in the 
closing scenes of the worst types of bronchitis. 

This delineation applies to the severer cases. 



218 DISEASES OF THE RESPIRATORY SYSTEM. 



CAUSES. 

It is incident to nearly every climate, and to every season. 
It is sometimes epidemic. As such, it has several times ap- 
peared in the United States. In the year 1812, it spread over 
the country with an unexampled mortality, and then received, 
as expressive of its local peculiarities, the title of 'pneumonia 
typhoides, spotted fever, cold plague. Prevailing endemically, it 
is found mostly in miasmatic districts. 

DIAGNOSIS. 

Easily recognised, except when masked, as it sometimes is, 
in epidemic cases. Physical signs become, in these cases, of 
considerable importance. 

PROGNOSIS. 

Of rapid progress, especially in epidemic instances. Dr. 
Chapman thinks, that at least nine out often, perish. 

AUTOPSIC APPEARANCES. 

The heaviest congestions of the pulmonary substance, bron- 
chia, pleura, alimentary canal (especially the upper part), of 
the liver, spleen, peritoneum, the right side of the heart, and the 
brain. 



TREATMENT. 

Venesection can seldom be pursued, — at least to any extent. 
A moderate amount of blood, thus taken, sometimes causes the 
greatest prostration. 

Cupping and Vesication at the seat of the local affec- 
tions, wherever they may be. The latter may here be much 
earlier resorted to than in the inflammatory form. 

An Emetic, 

Mercurial Purges. 



CONGESTIVE PNEUMONIA. 219 

Stimulant Diaphoretic s, — They proved the most effi- 
cient process in the epidemic which occurred to us some years 
ago. By stimulating the secreting vessels of the surface, they 
arrest the passive transpiration which is incident to the disease, 
and by determining to the surface, unload internal organs. 

The Dover's Powder, aided by the vapour bath and an 
infusion of the eupatorium, or pleurisy root, or serpentaria. 

On the supervention of a sinking condition, we may resort to 
the 

Sulphate of Quinia, in addition to the diaphoretics. 
This is peculiarly suited to miasmatic, and especially intermit- 
tent cases. 

In the final stage, the disease being unmitigated, we use the 
carbonate of ammonia, with warm wine whey, or toddy, cam- 
phor, dry heat, and other diffusible stimulants. Dry heat, how- 
ever, is a powerful stimulus, and only suited to emergencies. 

The disease breaking up, with a view to the assistance of 
expectoration, resort may be had to the cough mixtures already 
detailed. 

REGIME N, — In this, and every other variety of pneumonic 
affection, the patient should be confined to bed, with his head 
and shoulders considerably elevated, by which much relief is 
afforded to respiration. A change of posture sometimes affords 
relief, and is useful in overcoming certain passive congestions. 

THE TEMPERATURE should be a medium one. Fresh 
air is, however, a great requisite; and letting in the cold ex- 
ternal air, may sometimes prove a useful tonic to the debilitated 
lungs, restraining their inordinate secretions. 

THE DIET should, in the strictly inflammatory states, be of 
the lowest kind, — mere demulcent beverages. As the case be- 
comes typhoid, it may consist of tapioca, sago, &c, with the 
addition of a moderate portion of wine, or broth well seasoned. 

There seems to be an extraordinary disposition in these dis- 
eases to relapses, or more distant recurrences. Rush reports 
one individual as having had twenty-eight attacks. The ex- 
citing causes should, hence, be sedulously avoided. 



PLEURITIS ET PNEUMONITIS CHRONICA, 

OR 

CHRONIC PLEURISY AND PNEUMONIA. 

These affections are occasional degenerations of the acute 
inflammatory form, but never of the congestive or typhoid. 

Chronic pleurisy is constantly seen in the effusions into the 
pleural cavity of serum, or pus. That branch of the disease, 
which terminates in an effusion of serum, is discussed under the 
head of Hydrothorax. 

To phthisical degeneration of the lungs and their serous tissue, 
will the remarks now made chiefly advert. 

SYMPTOMS. 

A transitory stitch in the side, or oppression and a hard, dry 
cough. These symptoms continue weeks or months, attended 
by remissions and exacerbations. At last, however, the pain, 
oppression, and cough become more marked, the pulse quick, 
hard, and febrile, and before long, a well-developed hectic 
ensues. Digestion is sometimes much disordered, and the sto- 
mach highly irritable. 

In the closing scenes, the dyspnoea and cough become vio- 
lent; and there is an expectoration of a glairy, or a thick 
tenacious mucus, bloody, or puriloid, or purulent, and some- 
times so copious as to convey the impression that an abscess 
has burst. This is, indeed, occasionally true. 

The disease is, at other times, much more disguised. 

CAUSES. 

Besides being superinduced upon the acute affection, it may 



CHRONIC PLEURISY AND PNEUMONIA. 221 

be idiopathic or primary, and proceed from cold and other 
causes of inflammation. But being idiopathic, the constitution 
in which it occurs, is nearly always a vitiated one. 

DIAGNOSIS. 

Distinguish from phthisis. 

The pleuritic is discriminated from the pneumonic affection 
chiefly as in the acute form. In the former, also, when there 
has been effusion, the intercostal spaces are elevated to the level, 
or even above the level of the ribs. An ulcerative cavity ex- 
isting in the substance of the lungs, the cavernous rattle and 
pectoriloquism supervene. 

The distinction between a purulent, and a hydropic fluid in 
the pleura, is to be drawn from the general condition. The 
purulent expectoration of empyema is distinguished from that 
from the lungs, by a garlicky odour. 

PROGNOSIS. 

Chronic phlogosis is, in itself, manageable; but empyema, or 
purulent infiltration, having taken place, the case becomes a 
serious one, and particularly in a vitiated constitution. 

Empyema usually seeks an external opening. But the puru- 
lent secretion is apt to continue, and the passage to become 
fistulous. 

AUTOPSIC APPEARANCES. 

Essentially the same with those of the acute variety. 

The lungs are often found of diminished size, from the con- 
traction of the false membranes on the pleura, and the com- 
pression of a fluid in its cavity. 

In connexion with chronic pneumonitis, we often observe the 
mature developements of phthisis. 

Purulent infiltration of the cellular tissue is rarely, and an 
abscess almost never, detected. 

The abscess, constituting the apostematous consumption of 



222 DISEASES OF THE RESPIRATORY SYSTEM. 

the older writers, is formed in a cyst of coagulable lymph 
poured out from the pleura on the pulmonary surface. The 
enlargement of this abscess occasions a gradual compression, 
and such a diminution of the lung, as sometimes to induce the 
notion of its entire destruction. 

The bronchia are, at times, implicated, and may be found 
either contracted or dilated. 



TREATMENT. 

The leading object is to prevent structural lesions. 

Bleeding, General and Topical, 

Counter-irritation. 

The Antimonials. 

Low Diet, 

The phlogistic condition having thus been reduced, we 
resort to 

Mercury. — To obtain the constitutional effect betrayed by 
ptyalism. It is, however, contra-indicated by the tubercular 
disposition. Of all. remedies, mercury is most efficient in arrest- 
ing organic changes in the great viscera, or their envelopes. 

For the absorption of pus, when it has been secreted, a 
slender hope is afforded in the employment of 

Active Purgation, and The Diuretics. 

Iodine, internally and externally applied, has been much 
recommended. Dr. Chapman has not, however, seen from it 
the advantage promised by its friends. 

This treatment proving nugatory, a resort may be had, in 
empyema, to paracentesis thoracis, which has sometimes been 
successful. Though it is likely to effect no permanent benefit 
in old cases, it may afford relief; and may, in more recent 
cases, be followed by a cure. But it should be performed only 
in an emergency. 

The other treatment is similar to that in analogous states of 
tubercular consumption. 



DISEASES OF THE SENSITIVE SYSTEM. 
APOPLEXIA, OR APOPLEXY. 

SYMPTOMS. 

PREMONITORY. — May supervene without premonition; 
but is usually preceded by pain in the head, acute or dull; ver- 
tigo; drowsiness; flushed face; strange noises in the ear ; dis- 
order of vision, hearing, or taste ; hebetude of mind ; deep 
inspiration ; numbness of the fingers ; paralysis of the muscles of 
the face ; a full irregular pulse; cramps, or a sense of fulness, 
in the stomach. 

OF THE PAROXYSM— Mostly the individual falls down 
suddenly, deprived of sense and voluntary motion, and appa- 
rently as if in a profound sleep ; with a florid or livid counte- 
nance, stertorous breathing, frothing of the mouth, a dull, slow, 
interrupted circulation, hot head and cold feet, and little or no 
power of deglutition. 

SYMPTOMS ichen probably the stomach is primarily in 
fault. — Preceded by pain in the head ; severe stricture across 
the forehead ; a feeling of drawing in the muscles of the back 
of the neck ; vertigo ; great confusion of ideas ; tremors of 
the limbs; precordial oppression; cramps of the stomach, or 
bowels; nausea, or vomiting; pallor of the face; universally 
cold surface ; and an irregular pulse. Afterwards may suc- 
ceed convulsions, or paralysis (mostly hemiplegia), and other 
marked symptoms. 

In either the cerebral or gastric variety, life may be extin- 
guished at once. But this is seldom. 

Rupture of the heart, or larse vessels, is sometimes mistaken 



224 DISEASES OF THE SENSITIVE SYSTEM. 

for apoplexy. A fatal paroxysm of apoplexy seldom ends sooner 
than some hours, and usually endures several days. 

The paroxysm having lasted for some time, it is not unusual 
for the full, florid countenance to be exchanged for the pallid 
one ; or, on the other hand, for a more inflammatory action to 
be set up, with a hard, full, accelerated pulse, warm skin 
throughout, injected eyes, dilated or contracted pupils. 

When health has been restored, in other respects, the para- 
lytic affection, where it exists, is little improved, and the mind 
long remains impaired. 

CAUSES. 

PREDISPOSIN G. — Apoplexy occurs, usually, after the me- 
ridian of life ; and the period most subject to it is said to be 
between the ages of sixty and seventy. The male is much 
more inclined to the disease than the female. It is often found 
in men of large head, florid complexion, short thick neck, broad 
shoulders, expanded chest, tumid abdomen, low stature, and 
sanguine temperament. 

Other predisposing causes are habits of intemperance, or 
inactivity ; extremes of temperature ; antecedent lesions of the 
brain, or its meninges, and especially degenerations of the 
cerebral vessels, in consequence of chronic, and perhaps latent, 
inflammation ; derangements of the heart, great vessels, lungs, 
or any of the abdominal viscera, tumours of the neck, and 
whatever else may disorder the circulation. But particularly 
productive of apoplexy, is hypertrophy of the left ventricle of 
the heart. 

E X C I T I N G, — Excesses in eating and drinking, or irritating 
ingesta ; narcotics ; worms ; offensive sordes in the bowels ; 
constipation ; the suppression of an habitual discharge ; the 
repulsion of cutaneous eruptions; exposure to the sun, or hang- 
ing the head over a fire; long continuance in a warm bath, or 
the shock of a cold bath ; long exposure to a low temperature, 
and especially the use of stimulating food or drink under such 
circumstances ; violent exertion of the body, especially in a 
bent position ; intense mental exercise ; loud haranguing, &c. 



APOPLEXY. 225 



DIAGNOSIS. 



Paralysis of the brain, and in some of its forms coma, and 
lethargus, are essentially of the same pathological condition. 

In epilepsy there is much spasmodic and convulsive move- 
ment, and especially of the muscles of the face, while in apo- 
plexy there is a suspension of action in the voluntary muscles. 
In epilepsy, the muscles are rigid ; in apoplexy, relaxed. The 
paroxysm of the former soon passes off. 

A fit of intoxication may be distinguished from apoplexy, by 
an inquiry into the history of the case, by the odour of the liquor 
in the breath, and by a retention of sensibility in the upper lip 
to the impression of water dropped upon it. 

Distinguish from rupture of the heart, or of one of the great 
vessels, by death being in the latter case immediate, and the 
corpse being pallid. 

That form of the disease radicated in the alimentary canal, 
may be diagnosticated by the previous occurrence of dyspeptic 
symptoms, or by the patient's having been engaged in a de- 
bauch, or having swallowed a narcotic substance. The symp- 
toms of the paroxysm differ also. The stomach being the 
primary seat, there is usually much nausea or vomiting, the 
face pallid, skin cold, the pulse weak and diminutive, and the 
respiration comparatively little disturbed. The case very often 
resembles syncope. Cases originating in the uterus, &c, may 
be determined sometimes from their history. 

PROGNOSIS. 

The disease being uncomplicated with palsy, or, arising from 
some abdominal disorder, is the more curable. The danger, 
however, really depends upon the question, whether there be 
merely vascular congestion, or extravasations from rupture of 
vessels, or otherwise, or effusions from pre-existing irritation, or 
inflammation, or some of those derangements of structure, 
which are to be noticed. Recoveries sometimes take place 
even after the extravasation of blood. 

15 



226 DISEASES OF THE SENSITIVE SYSTEM. 

Apoplexy, in its more vehement forms, is always a most fatal 
disease. 

Symptoms of bad import are a weak, or exceedingly slow, 
or an irregular, and especially an intermittent pulse, or one 
not rising after venesection (showing that extravasation has 
occurred), very expanded or contracted pupils, convulsions, and 
particularly when of one side only, &c. 

AUTOPSIC APPEARANCES. 

The arteries, and veins of the brain and its meninges turgid, 
or even heavily engorged. Or only a portion of structure is 
involved. Most commonly, extravasation of blood, which may 
be deposited either on the surface, or, as is more frequent, in 
its substance. It is met with between the membranes, on the 
exterior, throughout the internal cerebral structure, about the 
basis of the brain, and in the ventricles. It may be pure and 
of florid colour, or dark grumous, or concreted, and may vary 
in quantity from a few drachms to as many ounces. The sur- 
rounding brain may be either softened, or hardened. Some- 
times the extravasations are serous or gelatinous. Acute in- 
flammation is not seldom discoverable. 

Besides, may be sometimes observed organic changes, and 
degenerations of the brain, or its envelopes, or disease of other 
parts of the body. These are, however, rather the causes of 
the affection. 

Fatal cases of apoplexy may occur without any appreciable 
change on dissection. Such instances may result from mere 
congestion; though excessive doses of opium, and ardent 
spirits appear to extinguish life, independently of the disorder 
they induce in the circulatory and respiratory organs. 

PATHOLOGY. 

The proximate cause of apoplexy, in most instances at least, 
is compression. This has been denied by M. Serres, of Paris, 
who asserts the incompressibility of the brain. But his experi- 
ments are nullified by the more cogent facts derived from other 



APOPLEXY 227 

sources, which show the symptoms of apoplexy to disappear 
immediately upon the removal of the coagulum, or pressure 
otherwise exerted, and the symptoms of apoplexy to supervene 
directly upon the application of artificial pressure to the brain. 
By M. Serres it is also alleged that the absence of palsy in- 
dicates the non-implication of the brain, and its presence the 
implication of that organ. This is doubted by Dr. Chapman. 

Abercrombie declaring that the cavity of the cranium is al- 
ways perfectly full, concludes, of course, against the possibility 
of any further accession of blood. He says, there is no more 
blood in the cranium in apoplexy than in any other state, and 
ascribes the disease "to an interrupted circulation in that organ 
from more blood entering from the arteries than can be returned 
by the veins." But if more blood enters by the arteries than 
can be returned by the veins, then his premise, that the cavity 
of the cranium is always full, cannot be true. 

Those cases of supposed apoplexy, which have been reported 
as being unconnected with any lesions of the brain, or its enve- 
lopes, may have been really instances of rupture of the heart or 
a great vessel ; or of hardening, softening, or other alterations 
of the brain, until recently overlooked ; or they may have been 
affections of the ganglionic system of nerves ; or the blood may 
have been retracted from the cerebral vessels by copious deple- 
tion, when it was, however, too late for the brain to recover 
from the effects of its previous compression, or retracted, as 
happens sometimes in inflammations, in the article of death. 

But while it is contended that the lesion of the brain giving 
rise to apoplexy, is usually dependent on compression, yet it 
must be admitted that the same condition may exist indepen- 
dently of compression ; and this is what was formerly called 
nervous apoplexy. 

Nosologists have commonly divided apoplexy into the san- 
guineous and serous varieties. But such a classification has no 
practical advantage. The better arrangement is into that form 
which is a primary affection of the brain, and that which is 
symptomatic. 



228 DISEASES OF THE SENSITIVE SYSTEM. 



TREATMENT. 

The head should be made to assume an elevated posture; all 
ligatures should be loosed, the boots or shoes should be drawn 
off, and fresh air admitted freely to the room. 

The skin is sometimes cold and collapsed, and the circulation 
extremely feeble. Here we must resort to the diffusible stimu- 
lants. But a state of high sanguineous action existing naturally, 
as it nearly always does, or having been excited by our stimu- 
lants, 

Venesection becomes the most efficient remedy. This may 
be carried usually to the extraction of thirty or forty ounces of 
blood in a robust individual, and may be required to be several 
times repeated. It being advantageous to draw the blood with 
rapidity, a vein is frequently opened in each arm ; but when the 
general action is feeble, the blood should be taken cautiously. 

The success of venesection is greater in simple congestion, 
than in extravasation. 

Local Bleeding. — By leeches or cups, or by a section of 
the temporal artery, or opening the jugular vein. The darker 
colour of the blood drawn from the jugular vein than that from 
the arm, would lead us to expect peculiar advantage from 
topical bleeding in this instance. Leeches to the anus, in imita- 
tion of haemorrhoids, might be advantageously tried. 

Cold Applications to the Head. — At first should be 
employed cloths wrung out of cold water. Such intense cold 
as ice, is only applicable to the highest state of reaction, when 
inflammation is menaced. 

Revulsion by sinapisms to the lower extremities. 

Emetics. — Especially to be used when the disease results 
from a loaded stomach, or from narcotic poisoning, or when 
the apoplexy has no sanguineous connexion. If we could as- 
certain that the condition of the brain was that of mere turges- 
cency, we might perhaps employ emetics in other instances 
than those above-mentioned. But it would be wrong to employ 
the measure in the case of extravasation. 

Active Purgatives.— Calomel, and its common adjuncts, 



APOPLEXY. 229 

castor oil and oil of turpentine, elaterium, or croton oil. To be 
given just after venesection, unless an emetic should be inter- 
posed. When the patient cannot swallow, the medicine may 
be introduced by the oesophagus tube. Stimulating enemata 
may be combined. The purgation may be repeated daily. 

Such a course having been pursued, and the case not relent- 
ing, if the disease be of purely gastric origin, the 

Diffusible Stimuli may be resorted to. It being of 
primary cerebral origin, however, antiphlogistics are commonly 
used. Here, also, may we apply blisters, first to the back of the 
neck, then to the scalp, and finally to the extremities. 

Mercury. — To be used internally, and externally to the 
shaven scalp. It is suited to the cases in which an extravasa- 
tion is to be absorbed, and is useful in correcting the secretions. 

A sinking condition coming en, the diffusible stimulants should 
be tried ; though death under such circumstances seems to be 
inevitable. 

As a great tendency remains to the reproduction of apo- 
plexy, the causes should be sedulously avoided, and the least 
premonition of the disease being given, blood-letting and other 
antiphlogistics are demanded. 



PARALYSIS, OR PALSY. 



DEFINITION, — Either a loss of power in the muscles, or 

loss of sensation, according as the nerves of motion or sensation 
are affected ; or both these states may be united. 

By hemiplegia, is meant palsy of one side of the body, from 
the head downward. By paraplegia, is meant palsy of a part 
separated by a transverse plane, from the hip downwards. 

There may be also general palsy (which, however, perhaps 
never occurs except in apoplexy), and partial palsy, as of a 
limb, or of a particular sense. 

Hemiplegia is more uniformly originated in the brain, and 
connected with cerebral disturbance, than paraplegia. 

SYMPTOMS. 

Paralysis may, as has been mentioned, be a symptom of apo- 
plexy, or it may, though independent of that disease, be pre- 
ceded by a train of symptoms much like those belonging to it, 
or it may supervene gradually during weeks, months, or years. 

The part assailed becomes flaccid, numb, cold and pale, with 
sometimes convulsive twitches. The sound muscles, being de- 
prived of antagonists, are contracted. The bowels are usually 
torpid, though the sphincter ani, or the sphincter vesica?, being 
paralysed, the excrement escapes involuntarily. 

The symptoms will obviously vary according to the seat of 
the disease, which may affect the nerves of any part of the 
body. Of viscera, the lower bowels and. urinary bladder are 
most frequently affected. 

In paralysis originating in the brain, the mental faculties are 
apt to become weak or disordered. 



PALSY. 231 

PARALYSIS AGITANS, OR TREMBLING PALSY, usu- 
ally commences in tremors of the hands or head. It may thus 
remain for even forty years ; but commonly advances until it 
pervades the whole body. 

Being of an apoplectic character, paralysis is prone to run 
to a speedy and fatal termination ; though in other cases it may 
be rapidly cured, yet on the whole the cures are slow. Often, 
after a rapid improvement in the beginning, the case becomes 
almost stationary. 

CAUSES. 

Both the predisposing and exciting causes are much the 
same with those of apoplexy. 

Paraplegia and local paralysis, however, more frequently 
proceed from some lesion of the spinal marrow, or of the nerve 
supplying the part. 

The influence of lead is a common cause. Mercury and 
arsenic are said to be productive of like effects. The applica- 
tion of cold to a system previously heated, is in some places a 
prolific source of the disease. Being associated sometimes with 
intermittent, or other autumnal fevers, miasma has been sus- 
pected to be an agent in its creation. 

DIAGNOSIS. 

Palsy and apoplexy are mutually convertible diseases, and 
may coexist. 

The principal point is to determine the primary seat of the 
disease ; whether in the brain, spinal marrow, nerve, or any 
particular viscus. This must be done by the associate symp- 
toms. 

PROGNOSIS. 

In proportion as the individual is older, so is the difficulty of 
cure the greater. 

Secondary or sympathetic palsy is more favourable than pri- 



232 DISEASES OF THE SENSITIVE SYSTEM. 

mary ; and palsy radicated in the spinal marrow more curable 
than that of the brain. Dr. Chapman has long observed that 
palsy of the right side is more intractable than that of the left. 

The first indication of returning sensibility is frequently a 
sense of formication, or a feeling like the creeping or stinging of 
ants. 

AUTOPSIC APPEARANCES. 

In paralysis seated in the brain, like those of apoplexy. It 
seems, from the contradictory reports of others, that no confi- 
dence can be placed in the allegation of those who state that 
paralysis of a certain part is always referable to a lesion in the 
same portion of the brain. 

We most uniformly find the seat of the lesions connected with 
palsy, to be about the corpora striata, thalami nervorum optico- 
rum, and the medulla oblongata. 

Similar phenomena are also observable in the spinal marrow, 
and the nerves, when they are the source of the disease. 

When the affection is of cerebral origin, the lesion will be found 
on the side opposite to that in which the paralysis is manifested. 

PATHOLOGY. 

Like apoplexy, to which it is nearly allied, palsy seems mainly 
to depend on pressure, whether we have regard to its being 
seated in the brain, spinal marrow, or individual nerves. The 
essential pathological difference between the two affections, con- 
sists in the degree and extent of the pressure, it being greater in 
both respects in apoplexy. But the energy of the nervous cen- 
tres may be interrupted, it must be admitted, independently of 
pressure. 

There is one modification of the disease which seems to re- 
sult from a want of irritability of the muscle ; and which, from 
its being usually brought on by cold, might be perhaps referred 
to rheumatism. 



PALSY. 233 



TREATMENT. 

1. IN THE ACTIVE STAGE, the measures are Antiphlo- 
gistic, and similar to those in the similar state of apoplexy. Dr. 
Chapman, however, insists upon the importance of Active and 
Persevering Purging. The disease being seated in the spi- 
na/ marrow, the local applications must be, of course, accom- 
modated. 

Tracing the attack, however, to cold, after these preliminary 
measures, sweating by the Vapour Bath, and the Dover's 
Powder, may be singularly successful. 

In secondary paralysis, the nervous centres being usually in 
the same pathological condition as when they are primarily 
affected, we should direct at first the same measures as in pri- 
mary paralysis; but this having been done, we should proceed 
to eradicate the disease, upon which the lesion of the nervous 
centres depends. 

In paralysis agitans, w 7 e should direct our remedies chiefly 
to the medulla oblongata, where it is probable the lesion is 
situated. 

In local palsy, if the affection depend upon pressure on the 
nerve by a tumour, this should be removed by an operation. In 
other cases it is usual to employ Local Depletion and 
Counter-irritation, as near as possible to the root of the 
affected nerve. Sometimes general depletion is demanded. 

2. In this stage, phlogosis, congestion, or irritation, is pre- 
sumed no longer to exist. Here the internal and external Ex- 
citants are indicated. Of the former, ammonia and mustard 
seeds are entitled to a high regard. But as an internal medi- 
cine, mercury, also, is of very great importance. 

Of external applications, may be mentioned a series of blis- 
ters, issues, setons, moxas, rubefacients, the hot or cold baths, 
frictions, &c. 

From the internal use of strychnia, or veratria, and the appli- 
cation of electricity, galvanism, and electro-galvanism, Dr. 
Chapman has seen little advantage. 



234 DISEASES OF THE SENSITIVE SYSTEM. 

The practitioner should be very cautious not to recur too 
speedily to the stimulating measures, remembering that, for the 
most part, especially in the beginning, the disease is one of 
oppression, and not of debility. Even in chronic states of it, 
we may find the pulse hard and corded, with other symptoms 
of a febrile movement, or it may be low from oppression. Un- 
der such circumstances, renouncing all tonics, we should betake 
ourselves to evacuations, and especially to purgation by elate- 
rium, which will be found to recruit the strength by a removal 
of the disease. 

The local applications, it may be again mentioned, should be 
made as nearly as possible to the seat of the lesion in the ner- 
vous centre ; or, when the nerve is affected, as nearly as pos- 
sible to its root. Frictions may be sometimes employed to the 
muscles, when the disease seems to be primary to them, and 
there is no excitement. 

The prevention of palsy is similar to that of apoplexy. 



EPILEPSIA, OR EPILEPSY. 



SYMPTOMS. 

F R M I N G, — The paroxysm may occur without any pre- 
monition, or it may, as is more common, be preceded by lan- 
guor, pain, or giddiness in the head, ringing or buzzing in the 
ears, fulness of the cerebral vessels, &c. On other occasions, 
the first intimation is the utterance of a loud scream or screams. 
Besides, there may be vomiting, or pain in the bowels, with 
looseness, or the reverse — constipation, — difficulty of respiration, 
palpitations of the heart, rumbling of wind in the intestines, 
and a rushing of it to the throat, copious discharges of pellucid 
urine, coldness of the extremities, &c. But the most extraor- 
dinary indication is what is called the aura epileptica. This is 
a sensation like that of a gentle breeze, or of a stream of water, 
or of the creeping of insects, which, arising generally at the 
extremities, proceeds to the head, upon reaching which, coma 
or convulsions ensue. 

OF THE PAROXYSM.— This being mild, the patient, without 
falling down, may be affected only by a shaking of the head, 
or agitation of the extremities, with frothing of the mouth, and 
distortion of the features ; these symptoms being succeeded by 
sleep and recovery. 

At other times the attack may amount to catalepsy, in which 
the position is firmly maintained, with general rigidity of the 
muscles, and mostly, with a state of stupor. 

More frequently, however, the individual, after a horrible 
shriek, falls to the ground. The muscles are contracted, as in 



236 DISEASES OF THE SENSITIVE SYSTEM. 

tetanus, or are affected with convulsions. The countenance is 
pale, or livid, and hideously deformed. 

DURATION. — May continue from a few minutes to many 
hours. The average duration is probably fifteen or twenty 
minutes. After the subsidence of the symptoms, the patient 
falls asleep, or is completely aroused. 

The F R E Q, U E N C Y of the paroxysm varies from the inter- 
mission of a very short time to that of a day, week, month, 
year, or more. 

TERMINATION S.— Death seldom takes place in the 
paroxysm, though occasionally it degenerates into apoplexy, 
and thus proves fatal. Continuing any great length of time, the 
stomach is apt first to give way ; there may be pain in the head, 
weakness, emaciation, paralysis, and decay of the intellectual 
faculties, or furious mania. But examples are numerous, where 
the disease has existed during a long life, without mental or 
bodily suffering. 

CAUSES. 

PREDISP0S1N 6.— It is often found in those with a nervous 
system of extraordinary sensibility, or irritability, or mobility, 
acutely alive to all impulses, physical or moral. Thus it has 
often occured to men of the highest order. But, on the other 
hand, we find it associated with stupidity, or even fatuity. 

It is most incident to childhood. It may be hereditary. 
Various lesions of the brain conduce to it, proceeding from 
injury, intemperance, excess of venery, &c. 

E X C I T I N 6. — Great exertions, violent emotions, certain sen- 
sations, or the mere force of imitation. 

These are the causes of primary cerebral epilepsy. The 
disease, however, may proceed secondarily from lesions of the 
spinal marrow, or of a nerve. 

It may arise also from irritations in the alimentary canal, — 



EPILEPSY. 237 

especially from dentition, worms, constipation, an excess or 
improper quality of the ingesta, narcotic, or other poisons. It 
arises also from irritations of the uterus, bladder, or other parts; 
from the repercussion of eruptions, the sudden arrestation of 
old discharges, hyperemia, and perhaps anaemia. 

DIAGNOSIS. 

Distinguish from hysteria by the great change of counte- 
nance, — the livid aspect, the fixed or staring expression of the 
eyes, gnashing of the teeth or firmly clenched jaws, foaming of 
the mouth, and the speedy subsidence into a tranquil sleep, or 
heavy stupor. Hysteria is accompanied by the globulus hys- 
tericus, by sudden transition from laughing to weeping, &c. 
But the case may be complicated with hysteria, or apoplexy. 

The disease proceeding from a lesion of the spinal marrow, 
the convulsions are extremely violent, and sometimes of a teta- 
noid nature, and the lesion may sometimes be detected by pres- 
sure on the spine. In a lesion of a nerve, besides the presence 
of tenderness, we may also be directed by the paroxysm being 
perhaps more apt to be preceded by the aura epileptica. 

Its dependency upon an irritation in some remote organ or 
tissue, must be determined by the associate symptoms which 
usually characterize such a condition. 

PROGNOSIS. 

More unfavourable when the disease is primary, or where it 
supervenes after puberty, or has long continued. 

AUTOPSIC APPEARANCES. 

When the disease proceeds from the brain, the phenomena 
resemble those of apoplexy and palsy; and also, when from the 
spinal marrow, there are similar phenomena, only seated in the 
latter substance. 

When the disease is secondary, the appearances, of course, 
are exceedingly diversified. 



238 DISEASES OF THE SENSITIVE SYSTEM. 



PATHOLOGY. 

(1.) The disease commencing in cerebro-spinal nervous irri- 
tation, the blood-vessels soon become involved in an irregular 
circulation, with topical congestion or inflammation, and parti- 
cularly of the brain. 

This pathology is substantiated by a reference to the causes, 
the symptoms, the necroscopy, the mutual convertibility of this 
disease, and apoplexy, and palsy, into each other, and their 
analogy, and lastly by the mode of cure. The essential condi- 
tion of the disease is cerebral irritation; this may either be 
primary or it may be secondary to the irritation of the spinal 
marrow, a particular nerve, or of remote parts of the body. 

This pathology is very similar to that of apoplexy and palsy. 
The difference in the manifestations, may perhaps be ascribed 
to the varied grades of violence, or to the particular seat of the 
lesion, — irritation of the medulla oblongata being said to produce 
epileptic symptoms. 

(2.) But the cerebral irritation may be as well connected 
with a deficiency as an excess of blood. This form of the 
disease bears more resemblance to syncope. It might be re- 
garded as spurious epilepsy. 

Yet there are cases in which true epilepsy is accompanied 
by no appearance of cerebral fulness. These, however, are 
commonly found in old states of the disease, in which probably 
the susceptibility of the brain has become so great as to produce 
the paroxysm under the operation of only a very moderate 
cerebral determination. 

TREATMENT. 

1. OF THE PAROXYSM. 

a. In the ordinary presentation. The patient should be at 
once placed in a position in which his head is elevated ; and all 
lio-atures, particularly the cravat, should be loosened. The con- 
vulsions being violent, the patient should be held down, and a 
tourniquet applied to the arm and leg of opposite sides. A piece 



EPILEPSY. 239 

of cork should be interposed between the jaws to prevent lace- 
ration of the tongue ; by which, also, the paroxysm is said to 
be sometimes arrested. The same effect is said to result from 
opening the fingers when firmly clenched; of the efficacy of 
which Dr. Chapman has seen several instances. 

Nervines, stimulating frictions, sternutatories, &c, are to be 
excluded. 

Cold to the Head. 

Stimulating Pediluvia. 

Aetive Enemata, 

Emetics judiciously used. They are chiefly, though not 
solely, adapted to the cases of primary gastric irritation. 

Blood-letting. — General, or local. Suited to cases with 
vascular fulness and excitement. It may obviate a conversion 
of the paroxysm into apoplexy or palsy. 

b. In THE FORM RESEMBLING SYNCOPE, CALLED LEIPOTHYMIA. 

The object here being to replenish the cerebral circulation, the 
head must be lowered; we must employ frictions, the fumes of 
ammonia to the nose and internal stimuli, and a sinapism to the 
back of the neck, or to the epigastrium, or to both. 

2. TREATMENT OF THE INTERMISSION, or treat- 
ment for a radical cure. 

It is important to ascertain the primary seat of the disease, 
the occasion of it, and the condition of the vascular system. 

Venesectio n. — When the system is full, which it generally 
is, and especially in the primary cerebral, or the uterine variety. 

local Bleeding may sometimes be substituted. 

Emetic s. — Especially suited to the gastric variety. 

Purgatives. — Useful by reducing the system, effecting de- 
rivation from the brain, and removing irritating contents from 
the bowels. It should be steadily persevered in. But its em- 
ployment, like the other measures, should be made to accom- 
modate the indications. 

Cups, or Leeches, and Blisters, or Moxas, to the seat 
of the local lesion, whether in the brain, spinal marrow, uterus, 
stomach, or elsewhere. Repelled eruptions should be solicited 



240 DISEASES OF THE SENSITIVE SYSTEM. 

by stimulating frictions ; or replaced by a pustulation with 
tartar emetic ointment. 

The anthelmintics and emmenagogues should be used, when 
demanded. 

Some cases proceeding from depressed portions of cranium, 
or the irritation of tumours, are curable by a surgical operation. 

This is Dr. Chapman's early treatment of the disease, though 
it is far more common to rely upon tonics, nervines, or stimu- 
lants. 

These remedies, though injurious at first, may become ad- 
missible, when we have as much as possible removed, by the 
course already detailed, irritation, congestion, or inflammation. 
But on the recurrence of a phlogistic condition, they should be 
immediately relinquished for a repetition of old measures. In 
such instances antimonials are valuable. 

Of Tonics, the phosphate of iron, and quinine, are the best. 

The preparations of zinc, and copper, especially the sulphate 
of copper and arsenic, are entitled to some regard. The nitrate 
of silver, in large doses, has acquired a great celebrity. 

Of narcotics, and nervines, it can be only said, that they allay 
the mobility of the system, and may be used as palliatives. 
Opium is to be preferred. 

Electro-galvanism may have, perhaps, some claims to atten- 
tion. 

Epilepsy is rooted ordinarily in some positive lesion, and when 
chronic, mostly of an organic nature. In such a condition, 
mercury, given in alterative doses, is our most valuable re- 
source. 

In the leipothymiac variety, iron, a nutritious diet, and other 
means calculated to enrich the blood, are indicated. 

PREVENTIVES. 

The patient feeling the aura epileptica, may succeed, some- 
times, in preventing the paroxysm by pressure on the nerve. 
Pressure on the epigastrium seems sometimes to succeed. 

The paroxysm being looked for at a certain time, an antici- 
patory detraction of blood, with cold to the head, and a stimu- 



EPILEPSY. 241 

lating pediluvium, are recommended, when there is cerebral 
determination, or vascular excitement. In other instances an 
opiate answers better. In the gastric variety, an emetic may 
be demanded. 

REGIMEN. 

The diet should be adapted to the pathology. Moderate ex- 
ercise on foot is desirable. The cold, or salt bath is sometimes 
of service. Quietude of mind should be carefully preserved. 



16 



HYSTERIA, OR HYSTERICS. 

SYMPTOMS. 

A most Protean and imitative disease. 

It may be preceded by various nervous phenomena, precor- 
dial tightness, flatulence, nausea, or vomiting; or may come 
on suddenly. On the latter occasion, the earliest indication is 
constriction of the chest, pain about the flexure of the colon, 
with a sense of fulness, and a rumbling which advances to the 
stomach, and thence to the throat, occasioning pressure as of a 
ball lodged there, and called globus hystericus. 

The preceding symptoms are soon Followed by coldness and 
shivering, a fluttering pulse, and such acute pain in the head as 
to be compared to the driving in of a nail, and hence called the 
clavus hystericus. The chilliness is followed by no reaction. 
Convulsions ensue, varying from the slightest to the most vio- 
lent. The trunk is contorted backwards, or forwards, or to the 
sides, the limbs are agitated, the hands clenched, the sphincter 
ani firmly closed, while the sphincter of the bladder may be 
relaxed, and emit copious streams of pellucid urine. During 
this period there are wild shrieks, incoherent expressions, alter- 
nations of laughter and crying, and a constricted respiration. 

As the paroxysm subsides, deep sighings or sobbings take 
place, eructations of wind, a gradual restoration of the senses, 
but without any recollection of the events of the paroxysm ; 
though sometimes, long after the subsidence of the fit, there re- 
mains a state of stupor, with flushed face, or, on the other hand, 
a pale cadaverous appearance, with great languor. There may 
be either a single paroxysm, or a succession of them for several 
days. 



HYSTERIA. 243 



CAUSES. 

May occur either in the male or female sex, though it is far 
more frequent in the latter. It hardly ever occurs prior to the 
age of puberty, or in advanced life. Single women and young 
widows are most liable to its attacks. It is most prone to 
affect the temperament of mobility, and sensitiveness, and the 
feeble. 

Its foundation is often laid in uterine disease (as the name 
imports) ; dyspepsia, or worms ; lesions of the brain, or spinal 
marrow ; and languor or depression following undue excite- 
ment, or attending misfortunes. 

But it may be at once excited by strong mental emotions. 

DIAGNOSIS. 

Be careful to ascertain the origin of the disease. Proceeding 
from a uterine, or gastro-enteric affection, it will be probably 
accompanied by symptoms, which when duly weighed will in- 
dicate the primary source of irritation. Being of primary 
cerebral origin, we find headache, a florid face, vertigo, tinnitus 
aurium ; while its arising from the spine, is denoted by tender- 
ness of some portion of the spine, and the violent tetanoid 
spasms. 

PROGNOSIS. 

There have been few cases reported of a fatal issue of the 
paroxysm. The disease may, however, degenerate into epilepsy, 
or mania. 

PATHOLOGY. 

An exalted excitement, congestion, or phlogosis of the brain, 
which is either primary, or the consequence of an irritation of 
the spinal marrow, uterus, alimentary canal, or other part. 



\ 



244 DISEASES OF THE SENSITIVE SYSTEM. 



TREATMENT. 

1. OF THE PAROXYSM. 

The milder attacks are usually treated by the application of 
pungent odours to the nostrils, or the internal administration of 
the antispasmodics. But Dr. Chapman is very distrustful of 
these measures, and when any great amount of cerebral affec- 
tion exists, they do harm. Dashing cold water on the face, xoitli 
sinapisms to the extremities, is a better practice. 

An Erne t ic— Almost always restores tranquillity, and ob- 
viates a renewal of the paroxysm. 

Purges and Enemat a. — Particularly where we suspect 
irritating colluvies in the intestines, or where constipation exists. 

Nervines and Antispasmodic s.— Opium does not 
answer so well as assafcetida and camphor. 

The tourniquet, applied to the arm and leg of opposite sides, 
may be serviceable in violent convulsions. 

In cases marked by permanent stupor and flushed face, 
general and topical bleeding, a blister to the nape of the neck, 
cold to the head, and stimulating pediluvia, are demanded. 

2. OF THE INTERMISSION, 

The indication is to obviate the disorder of whose irritation 
the hysteria is an effect. This being removed, we may resort 
to the nervines. 

The mind should be diverted, and kept happy. Green tea, 
and coffee, should be avoided, and the digestive organs well 
regulated. 



CHOREA, OR ST. VITUS' DANCE, 



SYMPTOMS. 

The invasion may be sudden, though it is usually preceded 
by a depraved, and often ravenous appetite, loss of vivacity, 
tumefaction, and occasionally pains, in the abdomen, consti- 
pated bowels, vitiated stools, and more or less of the cachectic 
aspect. 

The disease commences by a slight involuntary motion of 
different muscles, particularly of the face, then of those of the 
extremities, — the one or the other having precedence, they 
being rarely affected simultaneously. For example, when the 
arm is attempted to be raised, it is thrown into irregular con- 
vulsive action, or an effort being made to walk, the same 
happens, till, by continuance, the whole external muscular 
system participates, even to the impeding of deglutition, articu- 
lation, &c. In a state of repose, all the movements cease, to 
be revived by the most trivial excitement. 

Chorea is at first mostly a paroxysmal affection, with several 
attacks daily, or at longer intervals ; but, not arrested, it de- 
generates into a permanent condition, with scarcely any inter- 
ruption, except in sleep. Generally the mental and physical 
constitutions suffer very materially in the progress of the disease. 

CAUSES. 

Though incident to childhood, maturity, and old age, it is 
most apt to occur between the ages of eight and fourteen. It 
seems equally prone to attack all temperaments. It is caused 
by irritations of the alimentary canal, or uterus (being connected 



246 DISEASES OF THE SENSITIVE SYSTEM. 

with the suppression, excess, or vitiation of the uterine dis- 
charge) ; by the recession of eruptions, or the healing up of 
old ulcers, &c. ; cerebral, spinal, or nervous lesions; mental 
emotions, and imitation. 

DIAGNOSIS. 

We must endeavour to determine the location of the primary 
irritation. 

PROGNOSIS. 

Little immediate danger, though the degenerations of the 
disease have proved distressing, or even destructive of life. 
Occurring before the age of puberty, a good hope is afforded 
that the changes effected by that epoch, may eradicate the 
affection. 

AUTOPSIC APPEARANCES. 

Not very certainly ascertained, yet we may presume them to 
be the same in kind, with those of analogous affections. 

PATHOLOGY. 

In most instances the original seat is in the primae viae, or 
rather in the system of ganglionic nerves, and particularly the 
abdominal plexus, from which the impression is extended to the 
brain. The latter happens, whatever may be the primary point 
of the lesions, whether in the spinal marrow, or any other por- 
tion of the body. An irritation without such cerebral affection, 
could not be productive of the characteristic phenomena of 
chorea. Although we do not know precisely the nature of the 
pathological condition of the brain, it may be presumed to be 
similar to that of the kindred diseases. We may suspect that 
the basis of the brain, and especially the medulla oblongata, is 
the part affected. 



CHOREA. 247 

TREATMENT. 

As in the associate affections, we must regard the general 
condition of the system, and the primary seat of the affection. 
In a phlogistic condition it maybe requisite to bleed; and where 
the bowels seem to be the inceptive point of the disease, perse- 
vering purgation may be serviceable. Afterwards, or in an 
originally feeble condition of system, the vegetable and mineral 
tonics may be resorted to. Of the former, the cimicifuga has 
acquired a great reputation. Of the latter, Dr. Chapman re- 
commends, in particular, the subcarbonate of iron. 

To allay the muscular spasms, the nervines and narcotics, 
have been used. Opium is probably the best. Electricity and 
galvanism have not been very successful. An alterative course 
of mercury is often of great service. 

Local irritations must be combated by local bleeding and 
counter-irritation. But it should be recollected that in whatever 
part of the body the irritation may have originated, the cerebro- 
spinal axis ultimately becomes the subject of it, and that these 
measures should be addressed to it, as well as to the primary 
irritation. 

REGIMEN. 

The diet should conform to the general plan of the treatment. 
Cold, and especially salt bathing, is of great utility, when reac- 
tion follows. Exercise, and the regulation of the mind, are pre- 
eminently useful. 



TIC DOULOUREUX, OR NEURALGIA. 



A disease first distinctly noticed in the year 1756, by M. 
Andre, of France. The disease probably existed before, but 
was known by other names, as rheumatism, toothache, clavus 
hystericus, &c. 

The term neuralgia signifies nerve-ache. 

This disease may affect any of the nerves in the body ; and 
being seated in the nervous centre, the pain darts along the 
nerve to its minute ramifications, or conversely, arising at the 
branches, may be reflected on the centre. 

But in its course, it is apt to entangle other nerves of the 
same, or a different class, and render the aspect more complex. 

SYMPTOMS. 

The attack may come on without any premonition, or may 
be preceded by dyspeptic, uterine, or arthritic disturbance. 
Decidedly paroxysmal in the commencement, the paroxysms 
observe the laws of periodicity, in imitation of an intermittent. 
When chronic, however, it is less paroxysmal. 

Immediately precursory, are often to be noticed a sense of 
chilliness, slight disorder of stomach, pallor, and sometimes a 
sense of formication, or the aura epileptica. 

The paroxysm is made up of transient paroxysms, between 
which there are commonly remissions of comparative ease. 
The pain shoots along the nerve, following its distribution; and 
is sometimes terribly severe. The part is so tender that the 
slightest touch cannot be tolerated, — even less tolerated than 
firm pressure. Redness of the part sometimes occurs. Twitch- 



NEURALGIA. 249 

ing of the adjacent or remoter muscles, is occasionally observa- 
ble. The circulation is little changed. 

The duration of an attack varies from one or two hours to 
several days. The attack may not return for a week, month, 
or year. 

Neuralgia most frequently assails the three divisions of the 
fifth, and the facial portion of the seventh pair of nerves. It 
often attacks the intercostal muscles, those of the shoulder, 
loins, hip, the large articulations, the scalp, mammae, and tes- 
ticles. The brain, too, as well as other viscera, is subject to it. 
It may be confined to a spot no larger than a pea. 

CAUSES. 

PREDISPOSIN G,— Most incident to the period of life be- 
tween forty and sixty ; to the female, with a delicate, irritable, 
or shattered constitution. But exceptions to the last statement 
are numerous. It is apt to attack, in a mitigated form, girls at 
the age of puberty, or a little later. 

Mechanical injuries of nerves from wounds, or from the pres- 
sure of spiculae of bones or tight lacing ; the chemical action of 
the fluids in caries ; dental irritation in facial neuralgia ; mias- 
mata ; excessive venery, or masturbation ; dyspepsia, or lesions 
of any of the viscera (though it is probable that many cases 
attributed to these causes are really founded in atonic, or mis- 
placed gout) ; anaemia. 

EXCITING. — Exposure to cold, moisture, or a draft of cold 
air, undue corporeal or mental exercise, the emotions, or slight 
mechanical disturbance. 

DIAGNOSIS. 

Distinguished by the acute pain darting along the nerves, its 
occurrence in paroxysms, and the absence of inflammatory 
signs. 

It bears the closest analogy to neuritis, or inflammation of a 
nerve, and particularly in the case of the tooth. But this may 



250 DISEASES OF THE SENSITIVE SYSTEM. 

be distinguished from genuine odontalgia, by its being deep- 
seated, more obtuse, permanent, ultimately followed by swelling 
of the cheek and gums, and by its ending in suppuration, &c. 

It is distinguished from rheumatism by the difference of the 
predisposing and exciting causes, the difference of the seat of 
the pain, the absence of fever and inflammatory signs, its not 
impairing the constitution or structures, even when protracted, 
and the different effect of remedies. 

It is very important, though sometimes difficult, to elucidate 
the source of the disease. Emanating from the head, the case 
is preceded by giddiness or other uneasiness of the head, dis- 
order of some of the senses, congestion or increased action in 
the vessels of the brain, with a sympathetic affection of the 
liver or stomach. 

The symptoms of the superior cervical division of the spinal 
marrow, are pain in the scalp, shooting in various directions up 
the occipital even to the frontal portion, or laterally along the 
temples over the face, or sweeping behind the ears, or around 
the lower jaw, productive of rigidity of the muscles, impeding 
its movements and those of the head. 

In an implication of the inferior cervical portion, the pain is 
seated in the superior part of the chest, about the clavicle or 
scapula, or it runs down the arm, sometimes even to the fingers ; 
or passing forward, the superficial integuments, or the mammas 
in females, may be involved in exquisite soreness, or intense 
darting pains. 

The upper part of the dorsal division being affected with 
many of the symptoms just mentioned, it is more strikingly 
characterized by pain in the intercostal muscles, or margin of 
the ribs, or sternum, or epigastric region, or integuments behind 
the chest, the acuteness of pain being occasionally exchanged 
for dyspnoea in various degrees. 

The lower dorsal division being affected with some of the 
preceding phenomena, we have a sense of constriction across 
the waist, and great tenderness and darting pain in the parietes 
of the abdomen. 

In disease of the lumbar and sacral section, there is a dull 
ache, or acute pain in the muscles of the loins, and those of the 



NEURALGIA. 251 

hips, with a pain shooting down the lower extremities, and the 
tottering gait of an inebriate. 

The ganglia, or branches of the sympathetic, being involved, 
we have depravations of function or true neuralgic pains of the 
organs deriving their nerves from this source. Thus result pal- 
pitations, spasmodic asthma, angina pectoris, cramps, colic, 
gastralgia, &c. Connected with these disturbances, we may 
find great vitiation of the secretions, as in pyrosis, the diabetic 
discharge, &c. 

But generally in protracted cases one set of nerves implicates 
another. This is particularly the case of the spinal and gan- 
glionic nerves. The former, indeed, have seldom a distinct 
affection. In colic, is exemplified the implication of the nerves 
of the back, the pain in which is as great as that in the bowels. 

The most certain test of spinal disease is, undue sensibility be- 
trayed by pressure, or percussion, of the vertebrce, or sponging 
ivith hot water. 

PROGNOSIS. 

Rather difficult of cure, especially in old cases. Those are 
most favourable, which are seated in the spinal marrow; and 
those seated in the ganglionic nerves the least so, especially 
when connected with depravation of the abdominal viscera. 

The disease, however, cannot be regarded as fatal, and it 
often disappears spontaneously, or under the influence of some 
new disease, especially an eruptive one, or a revolution in the 
mode of living, or merely the shock of a mental emotion. 

AUTOPSIC APPEARANCES. 

In most instances no appreciable lesions have existed. In 
many, the lesions were probably the cause instead of effect of 
the disease. In a few cases the vessels of the neurilemma were 
found preternaturaHy turgescent ; and the nerve had an unna- 
tural floridness, was thickened, but wanted the effusion of 
serum, lymph, or pus, with the general changes of structure 
incident to neuritis. 



252 DISEASES OF THE SENSITIVE SYSTEM. 

PATHOLOGY. 

The disease, though having generally a local, may have also 
a constitutional origin. 

It seems certain, though inflammation of a nerve or nerve- 
centre may supervene upon neuralgia, that yet it is not an 
essential ingredient of it. Still, the disease may commence in 
a neuritis, or myelitis, or phrenitis, which may be exchanged 
for neuralgia, so as to justify a depletory plan of practice in the 
beginning, and a tonic one afterwards. Or, there may be in- 
flammation at the root of a nerve, and in the branches a mere 
neuralgia, which may enjoy an indefinitely protracted and in- 
dependent existence, after the reduction of the neuritis. 

The nature of the pain, and the effect of medicines, are much 
diversified by the location of the affection. It seems to be 
seated, however, only in the nerves of sensation, and is asso- 
ciated with a state of exceedingly exalted sensibility, — a state 
the opposite of that of palsy. 

TREATMENT. 

1. OF THE PAROXYSM. 

Venesectio n. — When there is plethora, or a local phlogistic 
condition, which, revived by cold or other means, reproduces 
the neuralgia. This inflammation may be situated in the neu- 
rilemma, and may be of a rheumatic character. 

Leeching. — Very serviceable in myelitis, neuritis, or phlo- 
gosis of the neurilemma, which, as appeared in the Pathology, 
may complicate, or originate neuralgia. It should of course be 
applied to the seat of the lesion. 

Caustics. — Preferable to epispastics ; and particularly valu- 
able when put behind the ear, in facial neuralgia. 

S t e a m i n g. — May assuage when there is exquisite tenderness. 

Ac u pun cturation. — When large muscles are involved, as 
those of the loins or hips, occurring mostly in gouty or rheu- 
matic subjects. 

Opium. — Nearly useless in facial neuralgia, it is of the 



NEURALGIA. 253 

greatest service in that of the ganglionic system, and above all 
in the attacks of the alimentary canal. It has also considerable 
power over irritations of the spinal nerves. 

The external application of morphia has been successful. 

Colchicn m. — Sometimes very serviceable. 

Nauscants, or vomiting. These have an extraordinary 
power to subdue pain, and are one of the best expedients in the 
present instance. Nausea may be protracted several hours. 

%. TREATMENT OFTHE INTERMISSION, FOR A 
RADICAL CURE. 

We should first endeavour to ascertain the fountain of 
irritation. Arising from a tooth, or a spicula of bone, or 
tumour, we must resort to a surgical operation. Those cases 
dependent on a slight wound, which, after healing, irritates the 
nerve, are most effectually relieved by the application of a 
caustic to convert it into a running sore. 

It would be needless to repeat the treatment adapted to the 
various sources in which the neuralgia may arise. 

An example or two will suffice. Judging the disease to 
spring from a phlogistic or congestive irritation of a certain 
part of the spine, we cup and use counter-irritation over the 
region, and enjoin a state of rest. Supposing it to lie in a 
similar condition of the sympathetic nerve, the same remedies 
are suited, and may be preferably applied to the back, instead 
of the front of the body, or directly over the organ assailed. 
Again, concluding that neuralgia is originated or maintained 
by disorder of the digestive apparatus, we must first rectify 
this. 

The primary causes of the disease having thus been over- 
come, a resort may now be made to tonics, &c, with a view 
of its eradication. 

Of the tonics, perhaps, the best is the Subcarbonate of 
Iron. It seems to have the property of lessening sensibility in 
most nervous diseases. It may be given in the dose of a drachm 
or more, several times a day. 

The nitrate of silver, and, especially in the ganglionic affec- 
tion, the subnitrate of bismuth, deserve our regard. 



254 DISEASES OF THE SENSITIVE SYSTEM. 

From the narcotics, Dr. Chapman has derived little advan- 
tage. Combined, however, with quinine, their virtues seem 
improved. 

Quinine and arsenic are adapted to all cases of a decidedly 
intermittent type. 

Emetics. — Very useful, and especially in neuralgia of the 
pericranium. 

Colchicn m. — In gouty or rheumatic habits. 

Electricity, Galvanism, and Magnetism, sometimes 
succeed. 

When our diagnosis is not clear, we may be compelled to 
follow an empirical and tentative practice. 

REGIMEN. 

Should be adapted to our views of the pathology of the case. 
It may here be stated that the excision of a portion of nerve 
has sometimes proved successful, and may be resorted to, as a 
last expedient. 



DISEASES OF THE GENERATIVE AND 
URINARY SYSTEM. 

i 

DIABETES. 

DEFINITION. — A permanent increase, with an alteration of 
the quality, of the urinary discharge. 

It is usually divided into two species, according to the cha- 
racter of the fluid. 

Diabetes Insipidus. 

Diabetes Mellitus. 

Some pathologists deny the distinction, while others maintain 
that the mellitic is the only form of genuine diabetes. Dr. Chap- 
man, without deciding the point, directs his attention chiefly in 
conformity with the latter view. 

Mere hyperuresis may occur under a variety of circum- 
stances. 

The first observation of diabetes mellitus was published in 
1684, by Willis. 

SYMPTOMS. 

Preceded for the most part by general derangement of health, 
especially derangement of the digestive and subsidiary pro- 
cesses. This state also accompanies the actual existence of the 
disease. We have also urgent thirst, parched mouth, costive- 
ness, pain and heaviness in the lumbar region, general weari- 
ness and aversion to exercise, and various dyspeptic symptoms. 

Continuing, with an aggravation of the preceding symptoms, 
we observe a loss of strength, emaciation, dyspnoea, vertigo, 



256 DISEASES OF THE GENERATIVE SYSTEM. 

headache, the gums ulcerated at the roots of the teeth, extreme 
restlessness, cramps and spasms of the extremities, weak mind, 
petulant temper, anaphrodisia, or impotency, and redness, swell- 
ing and excoriation about the mouth of the urethra, with phy- 
mosis. 

Not terminating suddenly, which, however, it sometimes does, 
the disease proceeds till the system is finally exhausted by hectic 
fever, with pulmonic affections, or an inveterate dropsy. 

The pulse throughout, though irritated, is generally weak. 
• The renal secretion, though usually excessive, varies from an 
indefinitely small increase, to thirty pints in twenty-four hours, 
which may be kept up for weeks and months. It is of a pale 
straw-colour, with a peculiar odour, resembling sweet whey, or 
milk, and somewhat of a saccharine, or honied taste. Mixed 
with it, w T e may observe albuminous matter like chyle, and occa- 
sionally clots of blood. The saline substances, though bearing 
to each other about the same relative proportion, are much 
diminished. The urea is much reduced, but not entirely want- 
ing. On evaporation of a pint of fluid, an extract remains of an 
ounce and a half. 

The secretion in diabetes insipidus, is insipid, pellucid, and 
very little changed. 

t 
CAUSES. 

R E 1 T E. — A decayed and shattered constitution. It is most 
incident to the debauched, in the decline of life, and especially 
to such as have been addicted to ardent spirits. Whatever dis- 
orders the stomach, or its dependencies, seems to predispose to 
the production of the disease ; also excessive venery, and what- 
ever debilitates the system. 

PROGNOSIS. 

It must be regarded as a most formidable disease, especially 
in decayed constitutions. 



DIABETES. 257 

AUTOPSIC APPEARANCES. 

The kidneys and liver are found most affected. The former 
is in some cases flabby, enlarged, and of an ash-colour, in other 
cases vascular and phlogosed. We may also observe morbid 
phenomena in the other abdominal viscera, and the lungs. 
Sometimes the whole force of the disease seems spent on the 
chylopoietic viscera, while at others it is spent on the urinary 
apparatus. 

The blood is deficient in animalization ; and when chemically 
examined, has not its ordinary proportion of fibrin and albumen. 

PATHOLOGY. 

There has been much discussion, whether the primary seat is 
in the kidneys, or digestive and assimilative organs. Dr. Chap- 
man has no doubt of its origination in the latter. He believes 
that, as in lithiasis, the secretion of the kidneys is modified by 
the state of the digestive apparatus. In the present instance 
they are caused to secrete sugar, and an immense amount of 
fluid. But the anormal condition of the blood, which results 
from the disordered state of the assimilative organs, assists in 
exciting the kidneys to the diabetic secretion. This excess of 
fluid eliminated by the kidneys, is counterbalanced partly by the 
deficiency of perspiration, though it is also supplied by the large 
quantities of liquid taken into the stomach, and by a conversion 
of the solids. 

The hepatic, pulmonary, and other affections are derived from 
an extension or sympathetic reflection of the gastric irritation. 

The symptoms of diabetes are totally different from primary 
disease of the kidneys. 

TREATMENT. 

The great indication is to rectify the depraved state of the 
digestive organs; and, here, much of the treatment applicable 
to dyspepsia will be found suitable. Afterwards the 

17 



258 DISEASES OF THE GENERATIVE SYSTEM. 

Astringents may be serviceable. With them may be 
combined 

Opium, which is also highly useful in allaying the nervous 
irritation. It may be given in large doses. The 

Warm Bath at bed-time, followed by stimulating frictions, 
is of vast importance. Its use is to relax the skin. With the 
same view may be administered the diaphoretics. The Dover's 
powder is, perhaps, the most elligible of the class. 

Venesection is confessedly of great importance ; and it may 
be resorted to, even when the low state of the system would 
seem to forbid. The quality of the blood greatly improves 
under its use. 

There being pain in the lumbar region, with a sense of 
heaviness, 

Topical Bleeding is demanded ; which may be succeeded 
by a blister. 

The diet should be exclusively animal. The only fluid admis- 
sible is milk. This, indeed, may be used to the exclusion of 
meat, in the stage of excitement. But. the dietetic rules of dys- 
pepsia will furnish many valuable hints. For drink may be 
directed lime water, or water acidulated with a mineral acid, or 
even plain water, according to circumstances. 

The kidneys, or other organs being painfully, or otherwise 
seriously affected, rest will be advisable; otherwise it will be 
well for the patient to take exercise, particularly in the fresh 
air. The regimen should be accurately observed, since by an 
infraction, relapses are extremely apt to recur. 



THE END. 



LEA AND BLANCIIARD'S LATE PUBLICATIONS. 



BIRD ON URINARY DEPOSITS. 

URINARY "DEPOSITS. 

THEIR DIAGNOSIS, PATIIOLOGY, AND THERAPEUTICAL INDICATIONS. 

BY G O L D 1 N G BIRD, A. M., M. D., &c. 

In One Octavo Volume, Cloth, with cuts. 

" One of the best fruits of this ' revival' in urinary pathology is the work of Dr. Gold- 
ing Bird, which we are about introducing to the notice of our readers. 

" In 1843, Dr. Bird delivered a course of lectures on the diagnosis and pathology of 
urinary sediments. They were published in the London Medical Gazette, attracted 
much attention at the time, and were suhsequenlly translated into German. These 
lectures form the groundwork of the present publication, though much extended and 
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*' From the space which we have given to the consideration of this little volume, our 
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line of investigation." — American Medical Journal. 



DURLACHER ON CORNS, BUNIONS, ETC. 
A TREATISE ON CORNS, BUNIONS, 

THE DISEASES OF THE NAILS, 

AND THE GENERAL MANAGEMENT OF THE FEET. 

BY LEWIS DURLACHER, 

Surgeon Chiropodist by Special Appointment to the Queen. 
In One small Duodecimo Volume, Cloth. 

"These important subjects are in this work lifted above the quackery which has 
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TRANSLATED FROiM THE GERMAN, 

AND ACCOMPANIED WITH ADDITIONAL NOTES AND OBSERVATIONS, 

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SIX NUMBERS ARE NOW READY. 

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A NEW AND IMPROVED EDITION OF 

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